
Class. 

Book. 



£ 



___ 



GcpightN?.. 






COPYRIGHT DEPOSIT. 



A TEXT-BOOK 



DISEASES OF THE 



NOSE AND THROAT 



BY 



D; Braden Kyle, A.M., M. D. 

Professor of Laryngology and Rhinology, Jefferson Medical College ; Consulting 
Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital; Fellow 
of the American Laryngological Association, etc. 



WITH 272 ILLUSTRATIONS, 27 OF THEM IN COLORS 



FIFTH EDITION, THOROUGHLY REVISED AND ENLARGED 



PHILADELPHIA AND LONDON 

W* B. SAUNDERS COMPANY 
19*4 



T?F 



- 46 



Copyright, 1899, by W. B. Saunders. Revised, reprinted, and recopyrighted Feb* 

ruary, 1901. Revised, reprinted, and recopyrighted January, 1904. Revised, 

reprinted, and recopyrighted December, 1907. Reprinted January, 

1909. Revised, reprinted, and recopyrighted November, 1914 



Copyright, 1914, by W. B. Saunders Company 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



©CI.A388602 

NOV 28 1914 



THIS BOOK 

IS 

Respectfully dedicated to my Teacher and friend, 
Dr. W. W. Keen. 



PREFACE TO THE FIFTH EDITION. 



In presenting the fifth revised edition of this work, as in pre- 
vious editions, the same general plan and arrangement have been 
adhered to. The entire book has been thoroughly revised. The 
following new articles have been added : Vaccine Therapy ; Lactic 
Bacteriotherapy in Atrophic Rhinitis ; Salvarsan in the Treatment 
of Syphilis of the Upper Respiratory Tract; Sphenopalatine Gang- 
lia Neuralgia ; Negative Air-pressure in Accessory Sinus Disease ; 
Chronic Hyperplastic Ethmoiditis ; Congenital Insufficiency of the 
Palate ; Lactic Bacteriotherapy in Pharyngeal Affections ; and an 
article describing the Removal of a Plate of Artificial Teeth from 
the Esophagus. The chapter on tonsils has been thoroughly re- 
vised and the surgical technic brought up to date. In the fol- 
lowing chapters alterations and additions have been made : General 
Consideration of Mucous Membranes; Simple Acute Rhinitis; 
Lithemic Rhinitis ; Diphtheritic Rhinitis ; Atrophic Rhinitis ; 
Nasal Syphilis ; Thymic Asthma ; Papilloma of Larynx ; Correc- 
tion of Septal Deformities (various methods) ; Diseases of the 
Anterior Nasal Cavities ; Ocular Symptoms in Diseases of the 
Nasal Cavities ; Complications in Ethmoiditis and Frontal Sinus- 
itis ; Streptococcic Pharyngitis ; Pneumococcus Infection of the 
Pharynx ; Vincent's Angina ; Syphilis of the Pharynx ; Anemia 
of the Pharynx ; Singer's Nodules ; Syphilis of the Larynx ; 
Laryngeal Tuberculosis ; Diplophonia ; Adductor Paralysis. 

A number of new illustrations have been added, and many of 
the old illustrations have been replaced by new ones. 

It has been the author's aim to give in full the etiology and 
pathology of the various diseases, so that by this detailed descrip- 
tion treatment is indicated and easily directed. As in the previous 
editions, the author has endeavored to take up each subject from 
a general standpoint and to consider under diagnosis, pathology, 
and treatment all systemic conditions in their relation to the 

5 



6 PREFACE TO THE FIFTH EDITION. 

special diseases of the throat and nose, as the same general funda- 
mental principles involved in general medicine are certainly appli- 
cable to any specialty. 

Literature, both American and European, has been carefully 
reviewed, and the opinions and methods expressed have been given 
careful consideration. 

I am indebted to Drs. George F. Doyle, Fielding O. Lewis, 
and Arthur J. Wagers for their valuable aid in the detail work 
necessitated in a revision ; also to Mrs. S. M. Fleming for valuable 
aid in preparing, arranging, and correcting of the manuscript, and 
especially to the W. B. Saunders Company for the continuance 
of their kind assistance in this as in previous editions. 

D. Braden Kyle. 
Philadelphia, Pa., 1517 Walnut St., 
November, 1914. 



PREFACE. 



It has been my aim to present to the reader the subject of 
Diseases of the Nose and Throat in as concise a manner as is com- 
patible with clearness. While the arrangement differs somewhat 
from many of the other text-books on this subject, it has been my 
aim to classify the diseases according to the pathological alterations 
caused by them. While some of the chapters necessarily show 
repetition, it is because of my desire to make each chapter com- 
plete in itself, so that the reader on turning to a certain subject 
may find under that heading the matter desired. 

While there are many things in the book that may seem 
superfluous to the specialist, yet, since the work has been pre- 
pared for the student and the general practitioner as well, there 
is a necessity for this fulness and apparent repetition. 

The lithographs and original illustrations are made from speci- 
mens prepared by the author in his own laboratory, and the draw- 
ings are from cases under his immediate observation. Some of 
the illustrations under anatomy are composite, being made from 
several other illustrations together with the original specimen. 
The cuts of instruments in many cases illustrate only one of 
many that might be used, but in the majority of instances the 
instruments are those used by the author, and the ones that have 
proved satisfactory in his hands. 

In treatment I have endeavored to be specific for definite con- 
ditions. While the doses given may seem positive and even 
dogmatic, it is understood that the dose of the drug must be indi- 
cated by the symptom to be relieved. Considerable space has 
been devoted to certain diseases which are somewhat rare, in the 
belief that when information is wanted on such subjects, it should 
be full and complete. 

I have purposely omitted reports of individual cases, and, in- 
stead, have grouped symptoms and generalized cases. 



8 PREFACE. 

In looking up the literature, all the standard works have been 
consulted, such as Bosworth, Ingals, Mackenzie, Browne, Seiler, 
Burnett, Sajous, Solly, Bishop, Bell, McBride, Scheppegrell, 
Cryer, Bryan, and Hall ; also monographs by John N. Mackenzie, 
Roe, Myles, Thorner, Jonathan Wright, Casselberry, Delevan, 
Eichardson, and others. The pathology conforms to the views 
advanced by Hamilton, Ziegler, Coplin, and Stengel. 

The following instrument-makers have kindly furnished elec- 
trotypes of various instruments : Messrs. Charles Lentz & Sons, 
Yarnall Surgical Company, Jacob Ostertag, and Williams, 
Browne & Earle, of Philadelphia ; George Tiemann & Company 
and E. B. Meyrowitz, of New York ; and Truax, Greene & 
Co., of Chicago. 

I am indebted to numerous writers for their many courtesies 
in furnishing reprints and copies of their various journal articles 
on special subjects. 

I am particularly indebted to Professor Keen for giving, in a 
special chapter, his own method of surgical operations on the 
larynx. 

I desire to thank Dr. W. H. King for his constant help in 
reference work and in reading the page proof, as well as for his 
valuable aid in making the index ; also Dr. J. Hervey Buchanan 
for his help in reference work. 

Acknowledgments are due to Mr. T. F. Dagney, the man- 
aging editor of the publishing house of W. B. Saunders, for his 
able assistance. 

D. BKADEN KYLE. 
1517 Walnut Street, 
Philadelphia 



CONTENTS 



CHAPTER I. 

PAGE 

Anatomy and Physiology of the Nasal Cavities 17 

Anatomy of the Anterior Nasal Cavities, 17 — Postnasal Cavity, or 
Nasopharynx, 25 — Physiology of the Nasal Cavities, 27. 

CHAPTER II. 

Illumination and Examination 30 

Illumination, 30 — Light, 30 — Mirrors, 31 — Examination, 33 — Posi- 
tion of the Patient, 34 — Rhinoscopy, 35 — Anterior, 35 — Posterior, 36 
— Instruments Needed for Office Work, 45 — Atomizers, 46 — Nebu- 
lizer, Inhalers, Applicator, 47. 

CHAPTER III. 

General Consideration of Mucous Membranes, Their Pathological 

Changes, and Relation to General Medicine 51 

General Remarks, 51 — Sialosemeiology, 53 — Inflammation, 59 — 
Clinical and Microscopical Phenomena, 60 — First, Second, and Third 
Stages, 61 — Varieties of Inflammation, 61 — (1) Catarrhal, 62 — (2) 
Membranous, 64 — (a) Croupous or Pseudomembranous, 64 — (b) Fi- 
brinoplastic, 64: — (c) Diphtheritic, 64 — (3) Hemorrhagic, 65 — (4) 
Gangrenous, 66 — (5) Suppurative, 66 — (6) Chronic Infectious, 66 — 
(a) Syphilis, 66 — (b) Tuberculosis, 67 — (c) Actinomycosis, 67 — 
(d) Glanders, 67 — (e) Leprosy, 68 — (/) Rhinoscleroma, 68. 
Nasal Bacteria and their Relation to Diseases, 68. 

CHAPTER IV. 

Diseases of the Anterior Nasal Cavities 72 

Acute Inflammatory Diseases, 72 — Taking Cold, 72 — Rhinitis, 
Acute, 74 — (1) Simple Acute Rhinitis, 74 — Simple Acute Rhinitis in 
Certain of the Constitutional Diseases, 82 — Measles, 82 — Pertussis, 83 
— Scarlet Fever, 83 — Variola, 83 — Typhoid Fever, 83 — Rheumatism, 
Acute Articular, 83 — Diabetes Mellitus, 83 — Diphtheria, 83 — Ery- 
sipelas, 84 — Scorbutic Rhinitis, 84 — Anemic Rhinitis, 84 — Scrofu- 

9 



10 CONTENTS, 

PAGE 

lous Rhinitis, 85 — Caseous Rhinitis, 86 — Epidemic Influenza, 87 — 
Lithemic Rhinitis, 90 — Acute Rhinitis in the Young, 91— Vaccine 
Therapy in Diseases of the Nose and Accessory Sinuses, 93 — (2) 
Membranous Rhinitis, 97 — (a) Croupous or Pseudomembranous, 97 
—(b) Fibrinoplastic, 100— (c) Diphtheritic, 102— Chronic Form, 102 
— (3) Occupation Rhinitis (Traumatic), 102— (4) Hyperesthetic 
Rhinitis (Hay Fever), 104— (5) Ulcerative Rhinitis, 104— (6) Edema- 
tous Rhinitis (Acute Edema), 105 — (7) Phlegmonous Rhinitis, 105. 

CHAPTER V. 

Diseases of the Anterior Nasal Cavities 107 

Chronic Inflammatory Diseases, 107 — Rhinitis, Chronic, 107 — (a) 
Simple Chronic Rhinitis, 107 — (b) Intumescent Rhinitis, 115 — (c) 
Hyperplastic Rhinitis, 116— Ozena, 123 — (d) Atrophic Rhinitis, 125 
—(e) Purulent Rhinitis, 139— (/) Nasal Hydrorrhea, 141— (g) Cya- 
notic Rhinitis (Edematous), 144 — (h) Specific Inflammations (Gran- 
ulomata), 145 — (1) Syphilis, 145 — (a) Congenital, 145 — (b) Acquired, 
145 — Salvarsan and Neosalvarsan in Syphilis of Nose and Throat, 
156— (c) Hereditary, 162— (2) Tuberculosis, 166— Lupus, 170— 
(3) Glanders, 174— (4) Leprosy, 177— (5) Actinomycosis, 179— (6) 
Rhinoscleroma, 180. 

CHAPTER VI. 

Diseases of the Anterior Nasal Cavities 183 

Inflammatory Diseases, 183 — Furunculosis, 183. 

CHAPTER VII. 

Diseases of the Anterior Nasal Cavities 184 

Inflammatory Diseases, 184 — Ulcers, 184 — (1) Non-infected, 185 — 
(a) Simple, 185— (1) Catarrhal, 185— (2) Herpetic, 185— (3) Eczem- 
atous, 185 — (4) Due to Foreign Bodies, 186 — (5) Neuroparalytic, 
186— (6) Scorbutic, 186— (7) Diabetic, 187— (8) Varicose, 187— 
Chemic, 187— (6) Compound Malignant, 188— (2) Infected, 188— 
(1) Tubercular (Lupoid), 188— (2) Syphilitic, 188— (3) Leprous, 
189— (4) Glanders, 189— (5) Diphtheritic, 190— (6) In Measles, 190 
—(7) In Rheumatism, 190— (8) In Scarlet Fever, 190— (9) In 
Small-pox, 190— (10) In Typhoid Fever, 190— (11) In Typhus Fever, 
190. 

CHAPTER VIII. 

Neuroses 191 

(1) Neuroses of Olfaction, 191 — Parosmia, 191 — Hyperosmia, 192 
— Anosmia, 192 — (2) Reflex Nasal Neuroses, 193 — (3) Respiratory 
Neuroses, 193— (4) Sneezing, 193— (5) Hydrorrhea, 194— (6) Hyper- 
esthetic Rhinitis, 194— (7) Nasal Cough, -208— (8) Reflexes Out- 
side of the Respiratory Tract, 212— (9) Migraine, 213— (10) Con- 
gestive Headache, 213— (11) Neuralgia, 213— (12) Sexual Reflexes, 
215. 



CONTENTS. 11 

CHAPTER IX. 

PAGE 

Diseases of the Anterior Nasal Cavities 217 

Non-inflammatory Diseases, 217 — Epistaxis, 217 — Varieties as to 
Cause, 217— (1) Traumatic, 217— (2) Local Nasal Lesions, 218— 
(3) Constitutional Conditions, 218 — (4) Vicarious, 219 — Hemo- 
philiacs, 223. 

CHAPTER X. 

Foreign Bodies in the Anterior Nasal Cavities 224 

(1) Inanimate, 224— (a) Rhinoliths, 224— (b) Miscellaneous, 226 
—(2) Animate, 228— (a) Parasites, 228. 

CHAPTER XL 

Neoplasms of the Respiratory Tract 232 

Classification, 232 — General Remarks, 233 — Papilloma of Nares, 
234 — Papilloma of Nasopharynx, 234 — Papilloma of Pharynx, 235 
— Papilloma of Larynx, 235 — Adenoma of Anterior Nares, 238 — 
Adenoma of Pharynx, 238 — Adenoma of Fauces, 239 — Adenoma of 
Larynx, 240 — Angioma of Nasal Passage, 240 — Angioma of Fauces, 
242 — Angioma of Pharynx and Uvula, 242 — Angioma of Tonsil, 243 
— Angioma of Larynx, 243 — Chondroma of Nasal Passage, 243 — 
Chondroma of Nasopharynx, 244 — Chondroma of Larynx, 245 — 
Exostosis, 245 — Fibroma of Nasal Passage, 247 — Fibroma of Naso- 
pharynx, 249 — Fibroma of Tonsil, 250— Fibroma of Larynx, 251 — 
Lipoma of Nares, 253 — Lipoma of Nasopharynx, 253 — Lipoma of 
Tonsil, 253 — Lipoma of Pharynx, 253 — Lipoma of Larynx, 254 — 
Osteoma of Nares, 254 — Myxoma (Nasal Polypus), 256 — Fibrous 
Nasal Polyp, or Myxofibroma, 261 — Fibromyxoma of Nasopharynx, 
263 — Mucocele, 265 — Mucocele of Nasopharynx, 265 — Mucocele of 
Larynx, 265. 

Embryonic Epithelial Tumors, 267— Carcinoma of Nasal Passage, 
267 — Carcinoma of Nasopharynx, 269 — Carcinoma of Soft Palate, 
270 — Carcinoma of Pharynx, 271 — Carcinoma of Tonsil, 272 — Car- 
cinoma of Larynx, 273. 

Embryonic Connective-tissue Tumors, 278 — Sarcoma of Nasal 
Passage, 278— Sarcoma of Nasopharynx, 280 — Sarcoma of Fauces, 
Pillars, and Soft Palate, 281 — Sarcoma of Pharynx, 281 — Sarcoma 
of Tonsil, 283 — Sarcoma of Larynx, 284. 

Mixed Tumors, 286 — Adenocarcinoma, 286— Myxocarcinoma, 286 
—Teratoma, 286— Glioma, 286— Telangiectoma, 286. 

Cysts, 287 — Simple or Retention Cysts (Mucocele), 287 — Cystoma 
(Hygroma, Hydroma), 288— Dermoid Cysts, 288— Blood Cysts, 288. 

CHAPTER XII. 

Diseases of the Anterior Nasal Cavities 289 

Septum, 289— (1) Malformations, 292— (2) Deformities, 293— 
(a) Deviations or Deflections— (1) From Disease, 294 — (2) Trau- 



12 CONTENTS. 

PAGE 

matic, 294— (3) Congenital, 296— (6) Synechia, 325— (3) Collapse 
of Nasal Alse, 327 — (4) Caries and Necrosis, 328 — Ulceration, 328 — 
Perforation, 331 — (5) Edema (Submucous Infiltration), 335 — (6) 
Abscess, 335— (a) Acute, 335— (6) Chronic, 337— (7) Correction of 
External Nasal Deformities, 338— (8) Syphilis, 346— (9) Tumors, 347 
— (10) Hematoma of the Septum, 347 — Angiomyxoma, 347 — Angi- 
oma, 347. 

CHAPTER XIII. 

Diseases of the Anterior Nasal Cavities 348 

Diseases of the Accessory Sinuses, 348 — Sphenopalatine Ganglia 
Neuralgia, 357 — Antrum of Highmore, 358 — (a) Catarrhal Inflam- 
mations, 359 — (1) Acute Catarrhal, 359 — (2) Chronic Catarrhal, 
361 — (6) Ozena, 364 — (c) Empyema, 364 — Acute Purulent Inflam- 
mation, 364 — (d) Chronic Purulent Inflammation, 366 — (e) Con- 
fined Suppuration, 368 — (/) Transillumination, 370 — Negative Air 
Pressure in Accessory Sinus Disease, 378 — (g) Specific Inflamma- 
tions, 379— (1) Tuberculosis, 379— (2) Syphilis, 379— (3) Glanders, 
379 — (4) Actinomycosis, 379 — (h) Acute Infectious Diseases, 379— 
(i) Emphysema, 379 — (j) Foreign Bodies in the Antrum, 381 — (k) 
Mucocele of the Antrum, 382 — (I) Bone-cysts of Accessory Sinuses, 
383 — Tumors of the Antrum, 383 — (m) Phlegmonous Inflammation, 
384 — (n) Diseases of the Ethmoid Cells, 384 — (1) Catarrhal Inflam- 
mation, 385 — Chronic Hyperplastic Ethmoiditis, 386 — (2) Ethmoidal 
Suppuration, 387 — (3) Mucocele and Non-infected Fluid-retention, 
392— (4) Specific Inflammations, 393— (5) Tumors, 393— (o) Dis- 
eases of the Sphenoidal Sinuses, 394 — (1) Catarrhal Inflammations, 
394— (2) Empyema of the Sphenoidal Sinus, 395— (3) Tumors, 398 
—(4) Specific Inflammations, 398— (5) Mucocele, 399— (p) Dis- 
eases of the Frontal Sinus, 399 — (1) Acute Catarrhal Inflammation, 
399 — Chronic Catarrhal Inflammation, 401 — (2) Empyema — (a) 
Acute Purulent, 402— (6) Chronic Purulent, 404— (3) Confined Sup- 
puration, 405 — (4) Mucocele, 413 — (5) Foreign Bodies, 414 — (6) 
Infectious Processes, 414 — (7) Tumors, 415. 

CHAPTER XIV. 

Related Pathological Conditions of the Nose and Accessory 

Sinuses to the Eye 416 

CHAPTER XV. 

Diseases of the Nasopharynx 421 

Inflammatory Diseases, Acute and Chronic, 421 — (1) Acute Naso- 
pharyngitis, 421 — (2) Simple Chronic Nasopharyngitis, 425 — Chronic 
Epipharyngeal Periadenitis in Adults, 431 — (3) Atrophic Naso- 
pharyngitis, 437 — (4) Hyperplastic Nasopharyngitis, 440 — (5) 
Rhinopharyngitis Mutilans, 441 — (6) Specific Inflammations, 442 — 
(7) Neuroses of the Nasopharynx, 442. 



CONTENTS. 13 

CHAPTER XVI. 

PAGE 

Diseases of the Uvula and the Soft Palate 443 

Malformations, 443 — (1) Bifid and Rudimentary Uvula, 443 — (2) 
Elongation, 444 — Inflammatory Diseases, 446 — (1) Acute Uvulitis, 
446— (2) Chronic Uvulitis, 447— (3) Ulceration, 447— Congenital In- 
sufficiency of Palate, 449 — X on-inflammatory Diseases, 450 — (1) 
Adhesions, 450 — (2) Congenital Absence of, 451 — (3) Xeuroses, 453 
— (4) Neuralgia, 453 — (5) Spasmodic Contraction, 453 — (6) Paralysis, 
453 — Acute Bulbar Paralysis, 454: — Chronic Bulbar Paralysis, 454 — 
Apoplectiform Bulbar Paralysis, 454 — (7) Herpes of the Fauces, 455 

CHAPTER XVII. 

Diseases of the Tonsils 456 

(1) Pharyngeal Tonsil, 457 — (a) Adenoid Vegetations, 457 — (2) 
Faucial Tonsil, 470 — (a) Acute Superficial Tonsillitis, 471 — (b) Cryp 
tic Tonsillitis, 474 — (c) Rheumatic or Gouty Tonsillitis, 479 — (d) 
Herpetic TonsiUitis, 480— (e) Abscess, 482— (1) Tonsillar, 482— (2) 
Peritonsillar, 482 — Membranous Inflammation, 485 — (/) Enlarge- 
ment or Hypertrophy, 487 — Surgical Tonsil, 491 — Imbedded Tonsil, 
491 — (g) Caseous Tonsillitis, 509 — (/?) Chronic Abscess of the Tonsil, 
511 — (i) Atrophy of the Tonsil, 511 — (j) Gangrene of the Tonsil, 511 
— Mycosis of the Faucial Tonsil, 512 — Actinomycosis of the Tonsil, 
512— (A:) Foreign Bodies, 513— (3) Lingual Tonsil, 513— (a) Acute 
Inflammation, 514 — (6) Acute Phlegmonous Inflammation, 515 — 
(c) Hyperplasia, 516 — (d) Mycosis, 516 — (e) Varices, 517 — (4) 
Laryngeal Tonsil, 517. 

CHAPTER XVIII. 
Diseases of the Pharynx 518 

Malformations and Deformities, 519 — Stenosis, 519 — Extrinsic 
Stenosis, 520 — Diverticula or Dilatations of the Pharynx, 520. 

Acute Inflammatory Diseases — (1) Simple Acute Pharyngitis, 521 
— (2) Infective Pharyngitis, 526 — Lactic Bacteriotherapy in Pharyn- 
geal Affections, 528 — (3) Membranous Pharyngitis, 529 — (a) Croup- 
ous, Simple Membranous, (6) Fibrinoplastic, (c) Diphtheritic, 530 — 
Nasal Diphtheria, 535 — Streptococcic Infection of Pharynx, 547 — 
Pneumococcic Infection of Pharynx, 548 — (4) Gangrenous Pharyn- 
gitis, 548 — Occupation-pharyngitis, 549 — (6) Hemorrhagic Pharyn- 
gitis, 551 — (7) Glandular Pharyngitis Lateralis, 552 — (8) The Phar- 
ynx in the Exanthemata and other Febrile Affections, 553 — Scarlet 
Fever, 553 — Small-pox, 554 — Measles, 555 — Erysipelas, 555 — Inter- 
mittent Fever, 556 — Gout, 556 — Typhus Fever, 557 — Typhoid 
Fever, 557 — Influenza, 557 — Varioloid, 558 — Chicken-pox, 558 — (9) 
Ludwig's Angina, 558 — (10) Vincent's Angina, 558 — (11) Angina 
Ulcerosa Benigna, 559. 

Chronic Inflammatory Diseases, 560 — (1) Simple Chronic Pharyn- 
gitis, 560— (2) Subacute Pharyngitis, 566— (3) Follicular Pharyn- 
gitis, 566 — (4) Hyperplastic Change in the Pharyngeal Structure, 572 



14 CONTENTS. 

PAGE 

— (5) Atrophic Pharyngitis, 573 — (6) Cyanotic Pharyngitis, 579 — 
(7) Rheumatic Pharyngitis, 580 — (a) Acute, 580 — (6) Chronic, 584 
— (8) Angioneurotic Edema, 585 — (9) Infectious Granulomata of 
the Pharynx and Nasopharynx and Tonsils, 586 — (a) Tuberculosis, 
586— (1) Lupus, 590— {b) Syphilis, 592— (c) Glanders, 597— (d) 
Actinomycosis, 600 — (10) Abscess (Retropharyngeal), 602 — (11) 
Urticaria, 604— (12) Herpes, 605— (13) Pharyngomycosis, 606— 
(14) Keratosis, 608. 

Non-inflammatory Diseases, 613 — (1) Pulsating Arteries, 613 — (2) 
Pharyngeal Aneurysm, 614 — (3) Anemia of the Pharynx, 614 — (4) 
Neuroses of the Pharynx, 615 — (a) Anesthesia, 615 — (6) Hyperes- 
thesia, 616 — (c) Paresthesia, 616— (d) Neuralgia, 617 — (e) Neuroses 
of Motion, 617— (1) Spasm, 617— (/) Paralysis, 617— (4) Foreign 
Bodies in the Pharynx, 619. 

CHAPTER XIX. 
Diseases of the Larynx 621 

Method of Laryngeal Examination, 622 — Autoscopy, 626 — Inspec- 
tion of the Posterior Wall of the Larynx, 627. 

Malformations and Deformities, 628 — (1) Congenital — (a) Sten- 
osis, 628 — (b) Dilatation of Pouch (Laryngocele), 629 — (c) Hyper- 
trophies, 629 — (2) Acquired Malformations — (a) Stenosis, 629 — 
(1) Syphilitic, 630— (2) Tuberculous, 631— (3) Lupus, 631. 

Inflammatory Diseases of the Larynx, 632 — Cough, 632 — (1) 
Acute Catarrhal Laryngitis, 634 — (2) Acute Catarrhal Laryngitis in 
Constitutional Diseases, 639 — (a) Erysipelas, 639— (b) Measles, 640 
—(c) Scarlet Fever, 640— (d) Small-pox, 640— (e) Typhoid Fever, 
641— (/) Typhus Fever, 641— (g) Influenza, 641— (h) Miasmatic 
Epiglottis, 641— (i) Rheumatism, 642 — (j) Purpura Hemorrhagica, 
642 — (3) Acute Laryngitis in Children, 642 — (4) Laryngismus Stridu- 
lus, 644 — (a) Congenital Stridor, 646 — (6) Spasm of the Larynx in 
Children, 646 — (c) Spasm of the Larynx in Adults, 648 — (d) Spas- 
modic Laryngitis, 649 — (5) Acute Epiglottis, 652 — (6) Traumatic 
Laryngitis, 653 — (7) Suppurative Laryngitis, 654: — (8) Rheumatic 
Laryngitis, 655 — (9) Edematous Laryngitis, 656 — (10) Chronic 
Edema of the Larynx, 661 — (11) Membranous Laryngitis, 661 — (1) 
Croupous, 661 — (2) Fibrinoplastic, 661 — (12) Hemorrhagic Laryn- 
gitis, 666. 

Chondritis and Perichondritis, 668 — Simple Chronic Inflamma- 
tions, 677 — (1) Simple Chronic Laryngitis, 677 — (2) Follicular Lar- 
yngitis, 684 — (3) Dry Laryngitis, 685 — (4) Cyanotic Laryngitis, 688 
— (5) Hyperplastic Laryngitis, 688 — Scleroma of the Larynx, 689 — 
Anemia of the Larynx, 689 — Hyperemia of the Larynx, 690 — 
Pemphigus of the Larynx, 690 — Singers' Nodules, 691 — Chronic 
Inflammations of the Larynx, 694 — (1) Syphilis of the Larynx, 
694 — (2) Tuberculosis of the Larynx, 703 — Laryngeal Hemor- 
rhage, 713 — Bronchoscopy, 714 — Technic of Laryngo-bronchoscopy, 
Esophagoscopy, and Direct Laryngoscopy, 718 — Foreign Bodies in 
the Larynx, 728 — Prolapse of Laryngeal Ventricles, 730. 



CONTENTS. 15 

CHAPTER XX. 

PAGE 

Voice and Speech 732 

Voice, 732 — Acoustics, 736 — Relation of the Voice to Hearing, 
738— Development of Speech, 744 — Speech Defects, 748 — Conditions 
Producing Change in Voice, 750. 

CHAPTER XXI. 

Neuroses of the Larynx 759 

Nervous Cough, 759 — Mogiphonia, 760 — Anesthesia, 760 — Pares- 
thesia, 761 — Hyperesthesia, 762 — Neuralgia, 762 — Hysterical Apho- 
nia, 763 — Functional Aphonia, 766 — Chorea of the Larynx, 766 — 
Dysphonia Spastica, 767 — Laryngeal Vertigo, 767 — Paralysis of the 
Vocal Chords, 769 — (a) Paralysis of the Superior Laryngeal Nerves, 
769 — (6) Recurrent Laryngeal Paralysis, 769— (c) Bilateral Abduc- 
tor Paralysis, 772 — (d) Unilateral Paralysis of Abductors, 774 — 
Paralysis of Individual Muscles, 774 — (a) Paralysis of Central 
Abductors (Arytenoids), 774 — (b) Paralysis of Internal Tensors 
(Thyro-arytenoids), 775 — (c) Bilateral Paralysis of Abductors 
(Lateral Crico-arytenoids) , 775 — (d) Unilateral Abductor Paralysis 
(Lateral Crico-arytenoids), 775. 

CHAPTER XXII. 

Intubation* of the Larynx 777 

CHAPTER XXIII. 

Tracheotomy 786 

Indications and Contra-indications, 786 — Operative Procedures, 
786 — Instruments, 787 — High Tracheotomy, 788 — Low Tracheot- 
omy, 789 — Laryngotomy, 790 — Complications and Dangers, 790 — 
Postoperative Care, 791. 

CHAPTER XXIV. 

Surgery of the Larynx 794 

Dangers, 796 — Thyrotomy, 796 — Palliative Tracheotomy, 797 — 
Laryngectomy, 797 — Artificial Larynx, 803 — Partial Laryngectomy, 
803. 



Index 805 




Fig. 1.— Sagittal section of head and neck : 1, frontal sinus ; 2, lateral cartilages of 
nose; 3, fourth turbinate (not constant) ; 4, superior turbinate ; 5, middle turbinate ; 6, in- 
ferior turbinate; 7, hard palate; 8, soft palate; 9, uvula; 10, arch of roof of mouth ; 11, 
anterior ethmoidal cells; 12, sphenoidal sinus; 13, Eustachian orifice; 13a, position of tubal 
tonsil ; 14, position of lingual tonsil ; 15, epiglottis ; 16, vestibule of larynx ; 17, position of 
vocal cords ; 18, trachea, showing rings ; 19, bodies of cervical vertebrae ; 20, spinal canal, 
showing foramina of exit of nerves ; 21, position of faucial tonsil ; 22, tongue ; 23, esophagus ; 
24, basilar process of occipital bone ; 25, nasopharynx ; 26, oropharynx. 



Diseases of the Nose and Throat. 



CHAPTEE I. 

ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES. 

Anatomy of the Anterior Nasal Cavities. — By the term 
" respiratory tract " is meant that combination and continuation of 
passages by Avhich the air in normal breathing passes to and from 
the lungs. It may be roughly divided into three portions : an 




Fig. 2.— Transverse section of the head, showing turbinates, antra, etc. (after Cryer) : 
s, septum ; m.L, middle turbinate ; o.m., ostium maxillare, through which a thread is passed 
on each side: u.p., uncinate process; m.m., middle meatus: i.t., inferior turbinate; i.m., 
inferior meatus :/., floor of nose : m.s., maxillary sinus, showing septa of bone dividing the 
sinus. Note the thin covering of the roots of the teeth, showing that the skull was taken 
from a white person. 

upper portion, extending from the nostrils to the upper boundary 
of the oropharynx ; a middle portion, comprising the oropharynx 

2 17 



18 



DISEASES OF THE NOSE AND THROAT. 



and the laryngopharynx, which it shares in common with the 
alimentary tract ; and a lower portion, extending from the glottis 
to the ultimate air-cells of the lung, and comprising the larynx, 
trachea, and bronchial tubes, with their successive subdivisions 
and terminal expansions. 

The upper portion of this tract proper is anatomically divided 
into two regions — a posterior, or postnasal space, and an anterior 
space, which is subdivided by a vertical septum into the two 
anterior nasal cavities. Each anterior cavity, extending from the 
anterior nares or nostrils in front to the posterior nares within, has 
a floor which is almost horizontal ; a roof, horizontal in its middle 
third, but inclining downward anteriorly and posteriorly; an 
internal vertical wall, formed by the nasal septum ; and an outer 
wall, which slants downward and outward ; so that the cavities 
may be briefly described as irregular four-sided passages of an 
approximately pyramidal form. The bony framework of each is 
as follows (Fig. 2) : 

The roof is formed in front by the nasal bone and the nasal 
process of the frontal, the middle portion by the cribriform plate 




Fig. 3.— Cartilage and bones of the septum of the nose: a, lower lateral cartilage; 
6, cartilage of septum ; c, perpendicular plate of ethmoid ; d, vomer; e, superior maxillary ; 
/, palatal; g, nasal ; h, frontal; i, horizontal plate of ethmoid ; k, rostrum of sphenoid. 

of the ethmoid, and the posterior portion by the under surface of 
the body of the sphenoid and the sphenoidal turbinated bones. 
The floor is formed in its anterior three- fourths by the palatal 
process of the superior maxillary, and in its posterior fourth by 
the palatal process of the palatal-bone. The outer wall is formed 
anteriorly by the nasal process of the superior maxillary and 



ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES. 19 



lacrimal bones ; in its middle portion by the ethmoid and the 
inner surface of the superior maxillary and inferior turbinated 
bones ; and posteriorly by the vertical plate of the palate and the 
internal pterygoid plate of the sphenoid bone. 

The inner wall is the septum narium, and is composed of both 
bone and cartilage. It is formed by the crest of the nasal bones 
and the nasal spine of the frontal, by the perpendicular plate of 
the ethmoid and the vomer, which receive in the notch between 
them the triangular cartilage of the nose, posteriorly by the rostrum 
of the sphenoid, and below by the nasal crest of the superior 
maxillary and palate-bones. Normally the 
septum is vertical, but after the seventh year 
it is frequently deflected, usually to the left, 
constituting the condition known as devia- 
tion of the septum. It varies in thickness 
from y 1 ^ of an inch at its anterior margin to 
-|- at its posterior. The remaining portion of 
the nasal cavity is known as the vestibule, and 
comprises that part embraced between the an- 
terior orifice and the termination of the osseo- 
cartilaginous boundary. The framework of 
each vestibule consists of an upper and a lower 
lateral cartilage, two or three smaller cartilag- 
inous plates (Fig. 4), and the median triangu- 
lar cartilage of the nose already mentioned. 

From the outer wall of each fossa there 
extend inward toward the septum, but not 
touching it, three, and sometimes four, shelf- 
like processes of bone, which from their scroll- 
like form are named the turbinated bones. 
Each is formed of a thin plate of bone, 
somewhat triangular in form, and so curled 
as to present a convexity upward, inward, and somewhat forward ; 
their lines of attachment being nearly horizontal and equidistant. 

The superior turbinate bone is the smallest and least rolled 
(Fig. 1). It arises from the lateral mass of the ethmoid, and 
hangs nearly perpendicularly in the nasal cavity. Its anterior 
margin coalesces with the middle turbinate bone, while the pos- 
terior is unattached, and in about one-third of all cases (Zucker- 
kandl) is split horizontally, thus forming a fourth turbinate bone, 
or the " concha Santoriniana." 

Beneath the superior is the middle turbinate bone (Fig. 1), 
larger than the former, broader, more rolled at its center, and pro- 
jecting horizontally instead of vertically. At its anterior free mar- 
gin is the " agger nasi," a small elevation directed downward, and 
opposite a corresponding slight elevation on the septum. These 
are important as marking the line between the olfactory area above 
and the respiratory region below. This bone also springs from 




Fig. 4.— Lateral carti- 
lages of nose : a, upper 
lateral cartilage ; b, lower 
lateral cartilage ; c, cell- 
tissue ; d, accessory or 
quadrate cartilages." 



20 



DISEASES OF THE NOSE AND THROAT. 



the lateral mass of the ethmoid and morphologically represents a 
detached portion of that bone. 

The inferior turbinate bone is the lowest of the three (Figs. 1 
and 2) as it is also the longest and largest. It is more highly de- 
veloped and compact than the others, and, unlike them, is a sep- 




Fig. 5. — Sphenoidal, ethmoidal, and frontal sinuses rafter Cryer): antero-posterior sec- 
tion, showing two frontal sinuses. The right has by disease extended over on the left side 
past the median line. A flap of bone (1) is laid up, showing the anterior, middle, and 
posterior ethmoidal cells and the sphenoidal sinus. The Eustachian orifice is to be noted. 
A square piece cut from the inferior turbinate shows a probe passed through the naso- 
lacrimal duct: r.f.s., right frontal sinus: l.f.s., left frontal sinus; i., infundibulum ; 
a.e.c, anterior ethmoidal cells ; h.s., hiatus semilunaris ; u.p., uncinate process; m.m., mid- 
dle meatus; i.L, inferior turbinate; p.n.d., probe in nasolacrimal duct; i.m., inferior 
meatus; h.p., hard palate; a.p., alveolar process; e.o., Eustachian orifice; s.m., superior 
meatus; s.s., sphenoidal sinus; s.L, superior turbinate; p.e.c, posterior ethmoidal cells; 
m.e.c, middle ethmoidal cells. 

arate bone. At its lateral origin it articulates with four bones — 
the ethmoid, the superior maxillary, the palate, and the lacrimal. 
Between each adjoining pair of turbinate bones and between the 
inferior turbinate bone and the floor of the nasal fossa is an elon- 
gated space termed a meatus. These spaces, from above down- 



ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES. 21 



ward, are known as the superior, middle, and inferior meatuses ; the 
fourth meatus (Fig. 1), if four turbinates be present, is unimportant. 

Into these meatuses open the accessory sinuses, which, being 
thus in direct communication with the nasal fossa?, are liable to 
the extension to them of diseased processes involving the nose. 
The accessory cavities form four groups, the sphenoidal, ethmoidal, 
and frontal sinuses (Fig. 5), and the maxillary sinuses, or antra of 
Highmore (Fig. 6). 

The sphenoidal sinuses are two irregular cavities about the 
size of a cranberry, separated 
from each other by a thin 
plate of bone. They are 
situated in the body of the 
sphenoid, and each is partly 
closed in front and below by 
the two thin plates known 
as the sphenoidal turbinated 
bones. The orifice thus re- 
sulting opens into the superior 
meatus of its respective side 
at its upper and posterior part. 
The roof of these sinuses is 
about ^ °f an mcn thick at 
its thinnest part, and separates 
them from the brain. They 
are absent in children, but 
develop and increase in size as 
age advances ; they are rarely 
symmetrical. 

The ethmoidal sinuses (Fig. 
5) are situated in the lateral 
mass of the ethmoid, and are 
more properly termed the ethmoidal cells. They are separated 
from each other by thin bony partitions, and are anatomically 
divided into three sets — anterior, middle, and posterior (Cryer). 
While this arrangement may differ from that of Zuckerkandl and 
other German teachers, yet the specimens shown by Cryer un- 
doubtedly justify this classification. The posterior, less numer- 
ous than the others, occasionally communicate with the sphenoidal 
sinus, and open into the superior meatus. The anterior cells open 
by means of small orifices, the ostia ethmoidalia, into the canal 
leading from the frontal sinus, or infundibulum, which in turn 
opens into the middle meatus at the hiatus semilunaris in its ex- 
treme anterior part. 

In some cases these cells communicate with the frontal sinuses, 
and rarely may also open into the orbit. 

The frontal sinuses (Fig. 5) are two in number, are somewhat 
larger than the sphenoidal sinuses, and lie between the two tables 




Fig. 6.— Maxillary and infra-orbital si- 
nuses (after Cryer i : wi".?., maxillary sinus, with 
its anterolateral side laid off; i.o.s., infra-or- 
bital sinus, with a piece of paper passed 
through the infra-orbital foramen. The root 
of a tooth is shown bare, having ulcerated 
into the maxillary sinus. 



22 DISEASES OF THE NOSE AND THROAT. 

of the skull in the frontal bone over the anterior portion of the 
nasal cavity, extending some distance over each orbit, and giving 
rise to the prominences over the root of the nose and orbits. Like 
the sphenoidal sinuses, they develop with advancing age. They 
communicate with the middle meatus by the infundibulum, as 
already described. 

A small sinus in the upper anterior part of the antrum of 
Highmore has been observed. It is quite separate from the max- 
illary sinus, and through it runs the canal carrying the infra-or- 
bital nerve. It is well shown in Fig. 6. 

The maxillary sinuses (Fig. 6), or antra of Highmore, are two 
large pyramidal cavities situated one in the body of each superior 
maxillary bone. The roof of each antrum is formed by the floor 
of the orbit, its floor by the alveolar process, its external wall by 
the facial surface, and its posterior wall by the zygomatic surface 
of the superior maxillary. It opens into the middle meatus 
(Fig. 2), near the posterior part of the hiatus semilunaris, 
by a circular opening, the ostium maxillare, behind which is 
occasionally a second opening, the ostium maxillare accessorius. 
These cavities vary much in size, both in races and in individuals. 
They are frequently crossed by thin laminae of bone. In the pos- 
terior wall are the canals transmitting the posterior dental vessels 
and nerves to the teeth, and on the floor may often be found con- 
ical projections caused by the roots of the first and second molar 
teeth. In the anterior region of the inferior meatus is the orifice 
of the lacrimal or nasal duct, leading from the lacrimal sac to the 
nose (Figs. 5, 168). 

The mucous membrane lining the accessory sinuses differs 
slightly from the nasal mucous membrane. The epithelial lining 
is a single layer of pavement-epithelial cells. The basement mem- 
brane and submucosa are much thinner than in the exposed 
mucous surfaces, and the gland element is largely limited to the 
orifice communicating with the nasal tract, the glands of the sinus 
mucous membrane being few in number. 

The bony walls of the nasal cavities and the accessory sinuses 
are completely lined by mucous membrane, which in front is con- 
tinuous with the skin, and at the posterior nares with the mucous 
membrane lining the pharynx. This membrane, which is vari- 
ously known as the pituitary or " phlegm-producing," the Schnei- 
derian, or the nasal mucosa, is intimately applied to the bony 
structure, varies in thickness and character in different areas, and 
modifies greatly the size of the nasal fossae and their accessory 
sinuses and orifices, as seen in the skull. It is thickest over the 
turbinated bones, somewhat thinner over the septum, and very 
thin over the floor, the under surfaces of the turbinated bones, 
and in the accessory cavities. 

The color of the nasal mucosa also varies. In the upper or olfac- 



ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES. 23 

tory region, including the roof, superior turbinated bone, superior 
meatus, upper third of the surface of the middle turbinated bone, 
and the corresponding portion of the septum, the membrane is a 
yellowish pink ; below this, in the respiratory region, it is a light 
pink ; and at the posterior ends of the turbinates the tint becomes 
whitish. In the accessory cavities the color is a pale pink. It 
must, however, be borne in mind that in the entire surface the 
color depends upon the vascular condition, deepening in plethora, 
and in anemia becoming paler. So pale may it become in the 
latter condition as, even where the membrane is thick, to show a 
yellowish tint from the color of the underlying structures. 

In structure the membrane shows three distinct component parts. 
The upper layer is of epi- and hypoblastic origin, and is composed 
of varied epithelial elements which rest upon the second layer or 
basement membrane. This layer is in turn supported by the third 
or submucous layer, varying in thickness, composed of white 
fibrous and elastic elements, and containing the vascular, lymphatic, 
nerve, and glandular structures. The lining membrane of the vesti- 
bule is cutaneous in character, and the epithelium is the flat pave- 
ment or squamous variety. In the deeper part, however, it con- 
tains both cutaneous and mucous elements, and at the junction of 
the vestibule and the nasal fossa proper it shades into true mucous 
membrane. In the olfactory region the mucous membrane is thin, 
comparatively non-vascular, closely adherent to the periosteum, 
and its epithelial investment is formed of columnar cells which 
for the most part present a sharp outline on their free surface and 
are not ciliated. Lying among them are the olfactorial cells of 
Schultze, supposed by most observers to be in direct communi- 
cation with the non-medullated filaments of the olfactory nerve. 

Beneath this epithelial covering, and opening on its surface, 
are numerous branched tubular glands — the glands of Bow- 
man. In the respiratory region the epithelium is of the stratified 
columnar variety — ciliated ; and interspersed numerously among 
the other cells are the so-called goblet- or chalice-cells. 

Glands. — The glandular structures are both mucous and serous 
in character, are of the racemose type, and open by small funnel- 
like (Fig. 12) orifices on the free surface of the membrane. These 
glands are most numerous at the middle and back parts of the 
cavities, and largest at the lower and posterior part of the septum. 

A most important feature is the large size of the venous net- 
works in the submucosa, which form large cavernous sinuses 
capable of sudden distention, giving to the tissue an erectile char- 
acter ; this is most marked on the surfaces of the middle and in- 
ferior turbinates and lower part of the septum, and from their 
resemblance to the cavernous structures of the penis, Bigelow has 
introduced the term turbinated corpora cavernosa. The term 
turbinated bodies comprises both the mucous membrane and the 



24 



DISEASES OF THE NOSE AND THROAT. 



bone invested, while the venous plexuses themselves have been 
termed " Schwellenkorper " (swollen bodies) by Zuckerkandl. The 
mucous membrane of the accessory sinuses is very thin, and its 
epithelium approaches the squamous variety in character. 




Fig. 12.— Section of normal mucous membrane : ex., epithelial cells ; 6., basement mem- 
brane ; c.t., connective tissue (submncosa) ; e.g., superficial gland ; m.g., muciparous glands; 
a., artery cut transversely; d., duct; o.d., orifice of duct; a', artery cut longitudinally ; 
x, open spaces from which gland structure has fallen in manipulation of section. To the 
right of the figure is seen a large vein (cavernous sinus). (Author's specimen.) 

Blood-supply. — The arterial supply of each nasal cavity is 
derived from the sphenopalatine branch of the internal maxillary, 
a minute twig from the small meningeal branch of the same, the 
anterior and posterior ethmoidal branches of the ophthalmic, the 
artery of the septum from the superior coronary, and the alveolar 
branch of the internal maxillary which is distributed to the lining 
membrane of the antrum. The sphenopalatine artery enters the 
fossa by a foramen of the same name just back of the superior 
meatus, where it divides into two branches, an internal, the naso- 
palatine or superior artery of the septum, which passes downward 
and forward along the septum supplying the membrane, and an 








X 




Fig. 13.— The upper figure represents the sphenopalatine ganglion and its branches; the 
lower figure, the nerves of the nasal septum, right side. 



ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES 25 

external branch, which subdivides into smaller branches supply- 
ing the lateral raucous membrane, the antrum, sphenoidal and 
ethmoidal sinuses. The infra-orbital artery sends branches to the 
antrum, also to the nose through the sutura notha. The anterior 
and posterior ethmoidal arteries enter their respective sets of 
ethmoidal cells, and after supplying them enter the cranium and 
give off numerous small nasal branches which, passing through 
the cribriform plate of the ethmoid, extend a short distance down 
the walls of the fossa. The anterior branches also supply the 
frontal sinuses. The anterior portion of the septum is supplied 
by the artery of the septum, which is a branch of the superior 
coronary of the facial, and enters the nose at the junction of the 
nostril and the lip. The descending palatine supplies the pos- 
terior end of the inferior turbinate and inferior meatus. The 
abundant vascular system with its free anastomoses explains the 
considerable hemorrhage often attendant upon operations in the 
nasal spaces. 

Nerves. — The nasal nerves (Fig. 13) are of special and general 
sensation. The olfactory nerves, or those of the special sense of 
smell, arise from the under surface of the olfactory bulb, pass 
through the foramina in the cribriform plate, and are roughly 
divisible into three sets : an inner set, spread out over the upper 
third of the septum ; an outer set, which is distributed over the 
superior turbinate, the upper part of the middle turbinate, and the 
surface of the ethmoid anterior to them ; and a middle set, supply- 
ing the roof between the distribution of the others. 

Branches of the sphenopalatine ganglion of the sympathetic 
nerve enter the nasal spaces and are distributed to the upper, mid- 
dle, and posterior parts of the septum, to the lower edge of the 
superior, and the surfaces of the middle and inferior turbinates. 
The anterior palatine supplies the middle and inferior turbinates. 
General sensation is supplied to the upper and anterior part of the 
septum, the nasal floor, outer walls, and the anterior surface of 
the inferior turbinate by the nasal branch of the fifth pair, while 
filaments from the anterior dental branch of the superior maxillary 
nerve are distributed to the inferior meatus and inferior turbinate. 
The Vidian nerve supplies the upper and back part of the septum 
and superior turbinate. 

Postnasal Cavity, or Nasopharynx. — The postnasal space 
or nasopharynx (Fig. 1) includes that portion of the upper respiratory 
tract comprised between the plane of the posterior nares and a hori- 
zontal plane extended backward at the level of the free margin of the 
soft palate. It is continuous in front with the nasal fossae through 
their respective openings, below with the oropharynx, and laterally, 
by means of the Eustachian tubes, with the tympanic cavities of 
the ears. The roof of this space, continuous in front with the 
upper limits of the nasal fossae, slopes gradually to the posterior 



26 DISEASES OF THE NOSE AND THROAT. 

and lateral walls, forming a dome-shaped structure, known as the 
vault or dome of the pharynx. These walls, beneath the invest- 
ment of mucous membrane, are formed by a rather dense fibro- 
muscular tissue, which in the posterior region is freely movable 
upon the mass of retropharyngeal cellular tissue separating it 
from the prevertebral muscles of the cervical spine. Laterally 
at the anterior and lower portion of the space, opposite the pos- 
terior terminations of the inferior turbinates, and about f of 
an inch from them, are the eminences marking the orifices of 
the Eustachian tubes. Anteriorly the boundary is formed by the 
posterior nares or choanse, the posterior edge of the septum, 
and the soft palate. Between the free border of the soft palate 
and the posterior pharyngeal wall is a space called the " isthmus/' 
which is closed during deglutition by the elevation of the velum 
palati or soft palate. 

Above the vault of the pharynx are the body of the sphenoid 
and the basilar process of the occipital bone, with the so-called 
basilar fibrocartilage. Posteriorly is the first cervical vertebra, 
and laterally are the internal pterygoid plates of the sphenoid and 
the petrous portion of the temporal bones. Anteriorly are the 
posterior bony margins of the anterior nasal cavities. The mucous 
membrane of this space is continuous with that of the nasal cavi- 
ties and of the oropharynx, as well as with the membrane lining 
the Eustachian tubes and their connected aural cavities. In its 
essential elements the mucous membrane presents but little varia- 
tion from the lining of the nasal cavity proper ; the epithelium 
being columnar and ciliated, with here and there goblet-cells, the 
three component strata of the membrane being well marked. It 
does differ from the nasal mucosa, however, in the absence of the 
large venous sinuses of the submucosa and in the presence of a 
greater number of glandular structures of both the follicular and 
racemose type. 

In the posterior part of the pharyngeal vault is situated a 
structure known as the third or pharyngeal tonsil, or tonsil of 
Luschka. This differs little in structure from the faucial tonsils, 
and is composed of a mass of adenoid tissue thickly placed, in 
which are numerous follicular glands. This tonsil extends from 
the median line on each side to a well-marked depression termed 
the fossa of Rosenmuller, or recessus pharyngeus, which separates 
it from the Eustachian orifice (Fig. 1). This fossa is an impor- 
tant landmark in locating the tubal opening. The surface of the 
tonsil is somewhat elevated, marked by depressions termed lacuna? 
or crypts, and studded with minute projections marking the gland- 
ular orifices. In the majority of cases there is a slit-like orifice 
in its lower part leading to a small sac beneath, termed by Luschka 
the pharyngeal bursa. The agglomerate glands are most numer- 
ous behind the projections which contain the Eustachian orifices, 
and are closely grouped together on the upper surface of the soft 



ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES. 27 

palate. The color of the membrane in the vault is a deeper pink 
than that observed in the nasal cavities ; it is lighter, however, 
around the Eustachian eminences, and shades to a yellowish tint 
immediately surrounding the orifices. 

The arterial supply of the nasopharynx is derived from the 
external carotid — branches of the ascending pharyngeal supplying 
the greater part of the region ; while the anterior portion receives 
the terminal branches of the descending palatine and spheno- 
palatine from the internal maxillary. The facial artery, through 
its ascending palatine branch, supplies the soft palate and the 
palatine glands. The venous return is through subdivisions of 
the internal jugular vein. 

The nerve-supply is derived largely from branches of the 
second division of the fifth nerve. The nasopharynx also receives 
branches from the glossopharyngeal nerve, the spinal accessory, 
and from the pneumogastric and superior cervical ganglion of the 
sympathetic, which contribute fibers to the pharyngeal plexus. 

Physiology of the Nasal Cavities. — The function of the 
nasal cavities is regarded by most physiologists as essentially three- 
fold, and is usually considered in relation to respiration, olfaction, 
and phonation. In addition, these cavities perform a very im- 
portant secondary part in the modification of certain functions of 
more or less intimately related organs. In considering the respira- 
tory function, it will be found that the external air, rarely fitted for 
entrance into the delicate structures of the lower part of the respira- 
tory tract, is modified by the upper passages in three important 
particulars — temperature, moisture, and purification from sus- 
pended foreign matter. Whether the temperature externally be 
above or below that of the body, after having passed through the 
nasal cavities, the inspired air will be found to be at almost blood 
heat on reaching the larynx. This alteration is brought about not 
only by the temperature of the area traversed, but also by the 
admixture of the air with glandular secretion, and by the moist 
vapor exhaled by the lungs, deposited upon the mucous membrane 
and kept at body heat by the underlying vascular supply. The 
air, moreover, is in inspiration to a greater or less extent filtered. 
This is brought about in two Avays : the larger particles are arrested 
by the vibrissa? or short, moderately stiff hairs which project from 
the anterior portion of the vestibule, as it were, " sieving " the 
air. The smaller particles brought in contact by the air-current, 
or precipitated by the moisture and lodging on the membrane, 
become entangled in the tenacious mucus, and with it are gradually 
propelled toward the nostrils by the constant vibrations of the 
ciliated epithelium. The air thus tempered, moistened, and freed 
largely from mechanical irritation, is prepared to pass over the 
delicate bronchial surfaces without injury to them. 

The distribution of the olfactory filaments has already been 
described (Fig. 13). Various theories have been advanced to ex- 



28 DISEASES OF THE NOSE AND THROAT. 

plain the mechanism of this distinctive function of the nasal 
spaces. The theory generally accepted supposes minute particles 
emanating from the odoriferous substance to be drawn in during 
inspiration, and lodging on the mucous membrane, there to be dis- 
solved in the secretion and thus come in direct contact with the 
terminal filaments of the olfactory cells of Schultze. It will at 
once be evident that any condition which reduces the area of 
normal membrane in the olfactory region lessens the quantity or 
vitiates the quality of the secretion, and, independently of any 
nervous involvement, will affect the sense of smell. The student 
must bear in mind, however, that the olfactory nerves are not con- 
cerned in sneezing and kindred phenomena attendant upon the 
inhalation of irritant fumes, the afferent pathway in this case 
being formed by branches of the fifth pair of nerves. 

Upon vocalization the nasal cavities exert a marked influence. 
The sound-vibrations, arising in the larynx, pass up the pharynx, 
and find in the postnasal space with its anterior openings the 
resonating chamber necessary for the production of the full, clear, 
sonorous tone of the normal voice. Closure of the cavities, either 
intentionally or by abnormal processes, produces marked alteration 
in certain of the fundamental sounds. Thus, if the nostrils be 
closed by compression with the thumb and finger, and the nasal 
" n " be spoken, the resultant sound, instead of being sharp and 
clear, resembles " ed." The sound is, moreover, clothed with a 
peculiar twang, which- — itself indescribable — passes under the 
term " nasal," though the nasal element is the very one lacking. 
On the other hand, if the same experiment be performed with 
" e " instead of " n," but little difference will be noted, except in the 
quality of the sound. In the first case, resonance was required for 
both pronunciation and quality ; in the second, only for the latter, 
and in its production the soft palate approached the pharyngeal 
wall, thus partially shutting off the upper chamber. It becomes 
evident, therefore, that pure resonant quality of voice and proper 
enunciation are possible only when the nasal cavities are in a 
healthy condition, free from obstruction, and the movements of 
the soft palate unimpeded. 

In addition to performing these functions, the nasal cavities are 
of great importance as accessories to others. Of these the most 
important are audition and taste. The former depends for its 
proper performance upon the patulous condition of the Eustachian 
tubes and their orifices, with the equalization of internal pressure 
and the exit of secretions, and the condition of the nasopharynx 
is largely determinative of each. To demonstrate the existent 
relation with the latter needs but the recollection of the familiar 
household expedient of holding the nose to assist in taking a 
nauseous dose. 

The nose has, moreover, a protective function, calling attention 



ANATOMY AND PHYSIOLOGY OF THE NASAL CAVITIES. 29 

to the presence of poisonous or irritant vapors, and some authors 
would claim a still further extension of this feature, asserting that 
the secretion upon the surface of the membrane has, in common 
with the secretion from the tonsils, a bactericidal influence. 

Others claims that the secretion, particularly from the naso- 
pharynx, is of prime importance in serving to liquefy the food, 
while yet others advance the theory that the mucous membrane 
has a function in the exchange of gases, throwing off carbon dioxid 
and taking up oxygen. 

Finally, in the list of nasal properties, there may be mentioned 
an element more properly belonging to psychology — namely, the 
relation of an odor perception to the memory, a familiar odor often 
bringing to mind scenes and circumstances long unthought of. 

As to the physiology of the accessory cavities, but little can be 
said. Theories without number have been originated in regard to 
them — that they lighten the bony framework of the skull, that 
they influence secretion, modify phonation, etc., but as yet no 
theory has received proof, and the truth probably lies in a combi- 
nation of many rather than in any one. 



CHAPTER II. 

ILLUMINATION AND EXAMINATION. 

ILLUMINATION. 

In order to study successfully the upper air-passages, not only a 
knowledge of the anatomy of the locality is necessary, but also a 
clear and distinct view of the parts themselves must be obtained. 
For this purpose illumination, either direct or indirect, by 
means of reflecting surfaces is essential. 

I4ght. — A Avhite light is preferable. The original simple 
method of Garcia and Tiirck is no doubt the best, but it is not 
practicable, since the sun's rays cannot always be obtained ; hence, 
recourse must be had to artificial light, such as the student's coal- 
oil lamp, the gas-flame, oxygen-hydrogen light, or the incandescent 
electric light. 

The cheapest of these is the student-lamp, supplied with a 
Rochester or Argand burner, and a Mackenzie's bull's-eye con- 
denser. This light can be made more intense and white by add- 
ing to the coal-oil a small piece of camphor, as suggested by 
Sajous. 

The best light is no doubt the one known as the Welsbach 
light, which consists of a cone-shaped hood placed over a Bunsen 
burner ; over this is fitted the Mackenzie condenser. This gives 
a perfectly white light, the only objection being the frailty of the 
cone, which is of some patented material, and is so delicate that 
the application of the slightest moisture, pressure, or even jarring 
destroys it. The ordinary gas-burner with the Mackenzie con- 
denser furnishes a very good light, but it lacks the clearness and 
penetration of the Welsbach light. The electric light is a bright, 
steady light, and if used direct is admirable ; but for a reflected 
light it is not so desirable, owing to its lack of penetration. 

The light supplied by one of the many batteries, while not so 
powerful as the others mentioned, is an admirable portable light, 
especially when the patient is confined to bed, and where examina- 
tions have to be made at the home or at the hospital. For the 
office, especially during the summer, it has the additional advan- 
tage of reducing the heat to a minimum, thereby adding to the 
comfort of both the patient and physician. Fig. 14 shows one of 
the most convenient of such batteries. 

While other lights are good, some expensive and complicated, 

30 



ILLUMINATION AND EXAMINATION 



31 



others inexpensive and uncomplicated, those described will answer 
for all practical purposes. 

Mirrors. — Reflecting" Mirrors. — The mirror especially 
adapted for this purpose is the one introduced by Czermak, or some 
modification of it. It consists of a round concave glass, vary- 




Fig. 14.-— Illuminating pocket set. 



to 4J inches, with a focal distance of from 



ing in diameter from 3 

8 to 15 inches. The reflector should have a central aperture 
which may be placed before the eye of the observer, enabling him 
to bring the line of vision parallel with and directly within the 
center of that of the reflected light. The mirror is attached to a 
head-band of rubber cloth, or preferably hard-rubber head-band 




Fig. 15.— Hard-rubber head-band. 



(Fig. 15). The attachment should be made by a ball-and-socket 
joint, or it may be fixed by the same means to an adjustable rod 
which is firmly attached to the condenser. This enables the 
observer to place the reflector in any position. The mirror can be 



32 DISEASES OF THE NOSE AND THROAT. 

placed either directly over the eye, or, as many prefer, worn upon 
the forehead. When it is worn in the latter position both eyes are 
used, and possibly a more accurate idea of appearance and distances 
can be secured. It is well to be able to use either method. When 
a large reflector is employed, it affords some protection as a shield 
to the face, which is rather an important factor, especially in hos- 
pital practice. 

In place of Fox's head-band with reflecting mirror, Klaar's 
headlight (Fig. 16) or the Phillips' lamp shown in Fig. 17 
may be used. 




Fig. 16.— Klaar's headlight, with head-band. Two slight apertures permit equal use of 
both eyes. A small lamp is carried ou an adjustable arm for focussing light. 



The other reflecting mirrors are the Laryngoscope and Rhino- 
scope, which are practically the same instrument, differing only 
slightly in the angle at which the mirror is placed on the rod, 
and the description of one will answer for both. This instrument 
is a small round plane mirror encased in a German-silver frame 
and attached, preferably at an angle of 105 degrees for rhinoscopy, 
and about 135 degrees for laryngoscopy, to a metal rod about 6 
inches in length. The rod should be of flexible material, so that 
by bending it the mirror can be placed at any angle desired, and 
should be of the proper size to be inserted in the universal handle, 
which should be made of light metal, fitted at one end with a 
socket and set-screw. 



ILLUMINATION AND EXAMINATION. 



33 



These instruments vary in size, the laryngoscope numbering 
from the smallest, No. 0, •§ inch in diameter, to the largest, No. 
5, 1 inch in diameter, but can be made of any size desired. The 
rhinoscopic mirrors are also made of different sizes, but those 
more often used, and which give the best satisfaction, are No. 1 
and No. 2, which are \ and •§ inch in diameter respectively. No 
arbitrary rule can be given for their employment, as the size used 
must be adapted to each particular case. A very satisfactory 
laryngoscope is now made which can be sterilized by boiling with- 
out injury to the glass. 

EXAMINATION. 

The student-lamp being attached to a solid vertical rod by 
means of a thumb-screw, the light can be raised or lowered so as 
to bring it into the correct po- 
sition for illumination. The 
gas-burner may be attached to 
one of the many wall-brackets 
with set-screw arrangements, 
or attached to a stand gas- 
pipe, which is secured to the 
floor or table by means of a 
base, the light being placed 
on a small sliding pipe work- 
ing within a larger one, and 
held in position by means 
of a thumb-screw, the joint 
being packed to prevent any 
leakage of gas. The reflector 
can be used on the head- 
band (Fig. 15), or attached to the mirror-rod, as shown in Fig. 




Fig. 17.— Phillip's electric head-lamp. 




Fig. 18. — Mackenzie condenser and reflecting mirror. 

18. When the rod attachment is used, the light can be so 

3 



34 DISEASES OF THE NOSE AND THROAT. 

arranged that the rays from the Mackenzie condenser will fall on 
the mirror and reflect directly in the median line of the examina- 
tion chair, which should be stationary. This is a decided advan- 
tage, especially to the student, or to one not accustomed to making 
frequent examinations. For in making an examination there 
should be three fixed points — the light, the reflector, and the 
patient. With the use of the mirror-rod, two points are fixed — 
the light and the reflector; while with the head-band only the 
light is fixed, both physician and patient being liable to move and 
destroy the direct angle of light obtained. 

Position of the Patient. — The patient should be seated 
upon a chair, or preferably a stool, arranged with a stand and 



Fig. 19.— Chair and stool for office work. 



screw similar to a piano-stool, so that its height can be con- 
trolled. In some cases the adjustable chair shown in Fig. 19 is 
advantageous. The light should be close to the right shoulder, 
and so adjusted that the lowest point of the circular frame sur- 
rounding the condenser is on a level with the lower edge of the 
patient's ear. 



ILLUMINATION AND EXAMINATION. 35 

In order to obtain the best advantage of the rays furnished by 
the flame, the reflector must be adjusted as previously described on 
page 33, so that the center of the cone formed by the rays will cor- 
respond with the middle of the mirror. This same point must be 
observed when directing the light into the cavity to be examined. 
The patient can be kept within the line of vision by placing the 
tongue-depressor in position, and supporting his chin with the middle 
finger of the hand holding the depressor. The method of examina- 
tion is, however, largely a matter of perfected method on the part of 
the operator. A special operating chair is recommended by many, 
as aiding in the performance of minor operations and examinations. 
Personally, I always use a low-backed chair or stool in my office and 
hospital work (Fig. 19). The disadvantage of the high-backed 
examining chair is that the patient will rest his head against 
the back, thus limiting backward motion of the head alone, leav- 
ing it free to move in any other direction. Although it is desired 
to have the patient's head free from any motion during the appli- 
cation, unless he is anesthetized this cannot be obtained. If, then, 
the patient should move suddenly he will naturally withdraw the 
head directly away from the operator, the act itself withdrawing 
the applicating instruments. On the other hand, if backward 
motion be restricted, lateral motion will almost certainly be re- 
sorted to, and the danger of injury be increased proportionately. 
While the operating chairs have some advantages, the simple 
method is to be preferred, the plain chair or stool never getting 
out of order just when needed, as is apt to occur with many of the 
finely-equipped pieces of office furniture. 

The description here will be limited to the method of exam- 
ination of the nasal passages, the laryngeal examination being 
described under its special section. 

Rhinoscopy. — The nasal passages are examined and the con- 
dition present recognized by illumination and direct inspection. 
If the view is obtained through the nostrils, the method is called 
anterior rhinoscopy. If, by placing the reflecting mirror or the 
incandescent light in the oropharynx, the illuminated parts are 
seen in a mirror (Fig. 21), the method is called posterior rhinos- 
copy. 

Anterior Rhinoscopy. — This examination is made by dilat- 
ing the nasal orifice, either by means of a speculum, or often by 
simply placing the thumb on the tip of the nose and pressing 
backward and upward. With the speculum the focus of illumi- 
nation can be made to fall directly upon the part to be examined. 
A number of instruments have been devised for dilating the nos- 
tril ; among the best is the bivalve speculum (Fig. 22), which also 
affords some protection to the parts when applications are to be 
made. The self-retaining speculum is of practical value only when 
operations are being performed, the objection to it being that, when 



36 DISEASES OF THE NOSE AND THROAT. 

placed in position and sufficient pressure is exerted to retain it, it 
soon becomes very uncomfortable to the patient. 

Grleason's or John Howard Allen's self-retaining nasal speculum 
(Figs. 20 and 24) is one of the best, although, for the comfort of the 




Fig. 20.— John Howard Allen's self-retaining nasal speculum. 

patient, it should not be allowed to remain too long in one posi- 
tion. 

A useful addition to the office paraphernalia is the cotton- 
holder shown in Fig. 25. The attachment for removal of the 
cotton from the probe is especially advantageous. Better than 
this is the receptacle for waste cotton shown in Fig. 23. 

The selection of instruments is largely a matter of usage, the 
operator becoming accustomed to that instrument which in his 
judgment seems to be the best. 

There are three positions in which the head should be placed 
for anterior nasal inspection. First, for the examination of the 
floor of the nose the head should be tipped forward and down- 
ward, as the floor of the nose tips inward, backward, and down- 
ward. Second, for the examination of the middle turbinated 
body the patient's head should be held in the natural position. 
Third, for the examination of the superior portion of the anterior 
nasal cavity the patient's head should be tipped well back. 

Posterior Rhinoscopy. — This can easily be accomplished if a 
few rules are observed. Carefully dry the rhinoscopic mirror by 
passing it quickly over the lamp to insure the evaporation of all 
moisture from its surface, and slightly heat it ; then touch it to 
the back of the hand — which is more sensitive than the palmar 



ILLUMINATION AND EXAMINATION 



37 



surface — to determine the degree of heat present. The patient 
is asked to breathe naturally and entirely through the nose, and 




i* 



;?•"- 






t 




^ 



Fig. 21.— Composite drawing, showing tongne-depressor in position, with view of naso- 
pharynx in the mirror. The drawing necessitated the incorrect position of mirror-rod. 

then to drop the lower jaw gradually, at the same time endeavor- 
ing to continue to breathe naturally through the nose ; by this 




Fig. 22.— Bivalve nasal speculum. 



maneuver the soft palate will remain relaxed. If the patient can be 
made to say " hah " with a nasal twang, the soft palate will drop. 



38 



DISEASES OF THE NOSE AND THROAT. 



The mirror should be held in the right hand, exactly as in the 
Spencerian method of holding the pen, so that the position may 




Fig. 23.— Receptacle for waste cotton. 

be controlled by rotating the handle by means of the thumb — the 
mirror being held by the index and second fingers, the thumb 
being merely a stay and rotator. It is then introduced, keeping 
the rod fully in the angle of the mouth on the left side, and 
passed backward -somewhat edgewise until it passes through the 
space between the uvula and the faucial pillar on the right side, 





MM ! W 1 

j I ra§ 



Fig. 24.— Gleason's nasal speculum. Fig. 25.— Cotton -reservoir and waste-box. 

being careful not to touch the parts. When fully within the 
pharyngeal space behind the palate, the handle is rotated slightly 
from right to left, bringing the reflecting surface around so as to 



ILLUMINATION AND EXAMINATION. 



39 



face the operator ; it can then by simple rotation be made to 
assume any position desired. All backward and forward move- 
ment of the wrist should be avoided, as that would be almost cer- 
tain to bring the mirror in contact with some part of the sensitive 
structures and cause retching. By manipulating the mirror-rod 
with the thumb and fingers, only lateral motion is obtained and 
this unpleasant result is averted. 

In making an examination of the nose, either anterior or pos- 
terior, if the instruments cause the least inconvenience to the 
patient, they should be withdrawn at once, and after waiting a 
moment or two, the examination re-attempted. I find that in a 
number of cases this posterior examination can be made without 
the aid of a tongue-depressor, which to many patients is an objec- 
tionable instrument. By inserting the mirror along the median 
line of the tongue, in many cases that member will with only the 
slightest pressure — and in some cases with no pressure at all — 
assume a position low enough to permit the rhinoscopic examina- 
tion. The examination should be made quickly and the mirror 
kept in position only a few seconds, repeating as often as neces- 
sary. 

In case a tongue-depressor is used, both the broad and narrow 
blade are equally good, depending largely upon the individual, al- 
though those shown in Figs. 26 and 27 will be found quite as conve- 




ys 



Fig. 26. 



Fig. 27 



Figs. 26 and 27.— Tongue depressors. 



nient as any, and can be so constructed that separate blades may 
be used for each individual, thereby assuring absolute cleanliness 
and freedom from possibility of infection. The fewer and simpler 
the instruments, and the shorter the time they are left in position, 
the better. In applying the tongue-depressor, which is really a 
tongue-controller, the tip of the tongue should be placed against 
the lower teeth ; the depressor , after being slightly warmed, is 
passed in with a gliding motion and not too far back, only slightly 
beyond the arch of the tongue. This caution is necessary for the 



40 DISEASES OF THE NOSE AND THROAT. 

reason that, if passed too far back and the tongue depressed, the end 
of the instrument will touch the sensitive parts of the base of the 
tongue or on the pharyngeal wall and excite a prompt reflex, 
which will interfere with the free movement of the mirror. 



Fig. 28.— Case of adjustable blades for tongue-depressor (Fig. 27). 

The tongue should be pressed downward and forward by a 
rotary movement of the depressor, the back of the instrument 
being made to revolve in the arc of a circle, the center of which 
is the teeth of the lower jaw. If this movement be made slowly, 
but with firm pressure, it will expose the whole of the lower 
pharynx, and at the same time will prevent the uvula from re- 
maining pendulous. 

The depressor should be held between the thumb and index 
finger, the thumb pressing against the angle, while the second 
finger passes under the chin of the patient. In this man- 
ner it can be firmly held in position and the movement of the 
patient's head, to a great extent, be controlled. It is a good rule 
to always use the depressor with the left hand, leaving the right 
hand free to manipulate the mirror. The size of the mirror used 
will depend entirely upon the space existing between the base of 
the tongue and the border of the soft palate, and that between the 
soft palate and the posterior nasopharyngeal wall. The largest 
mirror possible should be used, to obtain both better illumination 
and a larger image. At times, even when great care and patience 
have been used in these manipulations, the, patient is unable to 
control the movements of the palate, and the physician is forced 
to secure their obedience by medical or mechanical means. Among 
the last resorts to be employed for this purpose, recourse may be 



ILLUMINATION AND EXAMINATION. 41 

had to the application to the fauces of a 3 to 15 per cent, solution 
of cocain. This to many is quite unpleasant, producing a sensa- 
tion of choking or suffocation, but, as a rule, the inconvenience is 
only temporary. By the use of the small tongue-depressor (Fig. 
27), the uvula may be elevated, aiding materially in obtaining a 
view of the postnasal structures. 

As to the many palate-hooks and retractors that have been 
employed, while theoretically good, they are of little practical 
value. 

So far examination by reflected light only has been considered. 
Some specialists question the practicability of introducing into 
the nasal cavities a better light than can be furnished by means of 
reflectors. A very good method, however, of examining both the 
anterior and posterior nasal cavities is by the introduction of a 
small incandescent electric bulb (Fig. 29) into the postnasal space. 



Fig. 29.— Author's postnasal lamp. 

This lamp is placed on flexible wires, so that it may be bent to 
any angle desired, and it can be introduced within the postnasal 
space by following the rules given for the introduction of the 
rhinoscope. 

The lamp is quickly inserted back of the uvula, and the patient 
immediately closes his teeth upon its stem, holding the instrument 
firmly in position. I have had no trouble, even with very sensi- 
tive throats, in inserting and retaining this instrument when 
strictly adhering to this method. The lamp is enclosed in a small 
platinum cap with an aperture for the transmission of the rays, 
which also acts as a reflector and protects the parts from the heat 
generated by the current. By turning the current on and off, the 
lamp can be retained in the postnasal space for several minutes 
without any annoyance from heat. The cap is so arranged that 
its aperture can be turned in any direction desired, and, with the 
aid of the nasal speculum, an excellent view of the anterior and 
largely of the posterior nares can be obtained. By closing the 
mouth and nostrils of the patient, the condition of the accessory 
cavities can in a great measure be determined. A small electric 
lamp is also made for introduction into the nasal cavity, con- 
structed in a manner which prevents heating. 

If no fluid or tumor be present in the accessory cavities, the 
transmission of light is uninterrupted ; their presence will be 
shown by a dark outline ; however, the irregularity in the size of 



42 DISEASES OF THE NOSE AND THROAT. 

the antrum must be taken into consideration. Sufficient current 
can be obtained from any of the many storage batteries or from 
the street current. The use of the Rontgen ray will play an im- 
portant part in the future of laryngology and rhinology. By its 
use the condition of the bony structures of the throat, nose, and 
ear may be determined, as well as the accurate location of the 
position of foreign bodies. 

Hays' pharyngoscope (Fig. 30) is planned like an endoscope, 
with two small electric lights at the side of the tube. The advan- 
tage of the instrument is that it is to be used with the patient's 
mouth closed, nasal respiration causing the palatal opening to be 
perfectly relaxed and allowing of prolonged inspection of the naso- 
pharynx with little discomfort to the patient. The horizontal shaft 
is 8 inches long, and less than f inch wide at its widest part. The 




Eig. 30. — Hays' pharyngoscope and laryngoscope. 

inner two-thirds is flat, containing a central tube into which fits a 
telescope and two wire carriers. The two lamps, placed at the inner 
end, one on either side of the central tube, are powerful and water- 
tight. They can be attached to any rheostat or to a dry-cell bat- 
tery. The instrument cannot be sterilized by boiling, but is best 
disinfected by formalin fumes. The pharyngoscope is used like a 
tongue-depressor. It is placed firmly on the tongue until the end 
of the telescope is about y 1 ^ inch from the pharyngeal wall. 
The patient is then told to close his mouth and breathe through 
the nose. Inspection is now made by looking through the eye- 
piece of the instrument. 

A later form of nasopharyngoscope is that devised by Dr. Edgar 
M. Holmes, of Boston. His instrument (Fig. 31) consists of a 
single tube with small electric light at the extreme end and im- 
mediately beyond the lens aperture. The instrument is inserted 



ILLUMINATION AND EXAMINATION. 



43 



along the floor of either nostril until the tip is well within the 
nasopharynx, when the observer may, by rotating the instrument 
on its long axis, obtain a perfect view of the Eustachian tubes, 
the posterior ends of the turbinates, posterior end of nasal septum, 
and the upper surface of the soft palate. With the patient breath- 
ing naturally, with the mouth closed, the vocal cords may be seen, 
but the picture is reduced in size and not very distinct. On slowly 
withdrawing the instrument and, at the 
same time, rotating the lens it is possible 
to see a large part of the mucous surface 
of the naris. 

Having considered in regular order 
the apparatus necessary to make a com- 
plete examination and the methods to be 
employed in using them, a description of 
the normal appearance of the parts is 
next in order, their abnormal appearances 
being given under the special diseases in 
which they are characteristic. 

Anterior. — By placing the head in 
the positions described on page 36, 
through each nasal opening will be seen 
the anterior portion of the middle and 
superior turbinated bones on the outer 
side, and the anterior portion of the wall 
of the septum on the inner. 

By tilting the head slightly backward 
and inclining the chin slightly to the 
right or left, as either side is examined, 
the view will be more extensive. This 
procedure will fully expose the middle 
turbinated bone, the nasal roof, and supe- 
rior turbinated bone. If the head be 
lowered, a perfect view can be obtained 
of the floor of the nasal cavity and, in 
the majority of cases, the anterior portion of the inferior turbinate 
and the inferior meatus, while the middle turbinated bone will 
almost disappear from view. 

In their normal condition these parts are a grayish-pink with 
the exceptions of the anterior portion of the middle turbinated, 
which is dark pink, the superior turbinated bone, which is pink 
tinged with yellow, and the roof of the nose, which is also yellow- 
ish-pink, but of a lighter shade. The membranous covering of 
the septum is a bright pink, showing somewhat darker along the 
floor of the nose and with a yellowish shade if seen by transmitted 
light. 

Posterior. — In posterior examination the oval-shaped open- 




Fig. 31.— Holmes' nasopharyn- 
goscope. 



44 DISEASES OF THE NOSE AND THROAT. 

ings of the posterior nares, or choanse, are brought into view. The 
student must not forget, however, that the image shown in the 
rhinoscope is a reversal of the true position. Fig. 21 shows fairly 
well the position of the parts, but it must be remembered that the 
region is seen only in detail, and not as a whole. Above the upper 
surface of the soft palate and slightly back of it is seen the septum, 
broad above and tapering to a thin edge as it reaches the floor ; and 
on each side of it, though somewhat shaded, the nasal passages 
appear. 

Apparently resting on the floor of the nose is seen the inferior 
turbinated body, which appears as a somewhat elongated mass of 
a pinkish-gray color, and just above it is visible a considerable 
portion of the middle meatus. Projecting above this will be 
noticed the middle turbinated body, which appears as a somewhat 
elongated and slightly fusiform projection, the edges of which are 
yellowish-red, deepening in color toward the base. The superior 
meatus, which shows as a dark line above the posterior portion of 
the middle turbinate in the posterior nares, separates the middle 
from the superior turbinated body ; this latter shows dimly as a 
light reddish band which, owing to its position, is dimly lighted ; 
the postnasal lamp, however, clearly defines it. It shows the 
same yellowish-red color as the middle turbinate, and its edge 
slants slightly upward and forward, and appears as though sus- 
pended from the roof. 

As a rule, a good view cannot be obtained of the inferior 
meatus and floor of the nares by posterior rhinoscopy, but illumi- 
nation and anterior rhinoscopy outline the parts fairly well. If 
the mirror be now turned somewhat to one side, there will be seen 
the eminence surrounding the Eustachian tube, which is separated 
from the posterior wall of the vault of the pharynx by the fossa 
of Rosenmuller, the orifice of the tube showing as a grayish funnel- 
shaped depression. 

By elevating the handle of the rhinoscope, causing the mirror 
to incline nearer the horizontal, there is brought into view the half- 
dome-like cavity of the vault of the pharynx, which presents a 
rather irregular outline, its glandular tissue (pharyngeal tonsil) 
rendering its surface irregular and furrowed. This irregularity 
depends largely on the age of the patient. Usually in adult life 
the pharyngeal tonsil has atrophied, the irregularities then depend- 
ing on the amount of atrophy. In some cases very little atrophy 
has taken place, while in others no evidence of the tonsil can be 
seen. In children the pharyngeal tonsil is always present, some- 
times rudimentary, and again enormously enlarged. This enlarge- 
ment may be mere swelling or actual tissue-proliferation. The 
color of the tissue seen by this view varies with the age of the 
patient, often in the young showing a deep-red color, while in the 
adult more of a pinkish-gray. The parts appear much smoother 



ILLUMINATION AND EXAMINATION. 45 

as the view passes down, until there is seen the smooth, shining, 
dark-red surface of the lower pharynx. With children it is often 
difficult to obtain a good view of the postnasal tissue, but an ap- 
proximate idea may be formed by introducing the index finger 
back of the soft palate and quickly sweeping it over the tissues. 

It must also be borne in mind, in examining the mucous mem- 
brane of the upper air-passages, that the long exposure of such a 
delicate membrane to the reflected rays of light, and the changes 
produced by the action of underlying muscles, alter the color of 
the membrane in a very short time. The first view obtained gives 
the true color, and therefore the examination should not be pro- 
longed. This is especially true of the pharyngeal and the laryn- 
geal membrane. 

Instruments Needed for Office Work. — A brief descrip- 
tion of the instruments necessary in treatment of the anterior and 
posterior nasal cavities may not be amiss here, leaving those 
required in special treatment to be described under the special 
conditions demanding them. 

In local treatment of the mucous membrane of the upper air- 
passages, the essential element is cleanliness, and for this purpose 
various forms of cotton applicators, douches, atomizers, etc., have 
been devised. To reach the diseased area with medicating fluids 
depends on our ability to cleanse the membrane thoroughly, and 
this can best be accomplished by reducing the cleansing fluid to a 
state of minute atomization or by the employment of the douche. 

Atomizer. — Many atomizers have been placed on the market 
— some elaborate, complicated, and expensive ; others plain and 
simple in construction, but all involving the same general prin- 
ciple. 

The atomizer giving the most satisfaction is the one simplest 
in construction. I believe that with the ordinary single-bulb 
hand-atomizer, one's work can be quite as well performed as with 
more complicated apparatus, the pressure being easily controlled 
to suit the sensitiveness of the mucous membrane in each partic- 
ular case. The majority of the compressed-air apparatuses create 
entirely too strong a spray for such a delicate membrane as that 
which lines the upper air-passages ; in fact, a case of rhinitis can 
easily be aggravated by using too strong a spray, and when such 
apparatus is used, this danger must be carefully guarded against 
by pressure regulators. 

An ordinary straight-tube atomizer, constructed on the same 
principle as that of the Eichardson atomizer and Sass's spray 
tubes, is quite satisfactory. The straight-tube atomizer is made 
with screw top, metal cap and tube, and the diameter of the tube 
should be not more than \ inch, at least 5 inches in length and 
slanted slightly upward. The bottle is graduated, thereby ena- 
bling the patient to obtain a definite amount of the solution used, 



46 



DISEASES OF THE NOSE AND THROAT. 



By careful manipulation of this atomizer, the spray can be so 
directed as to reach any portion of the anterior region, and by 
inserting the tube carefully along the floor of the nostril, the 
spray can be thrown into the nasopharynx. In cases in which 
there exists malformation or hypertrophy of the nasal structures, 
this is difficult and in a few cases impossible ; yet if the tube be 
carefully inserted, using no force, but rather directing in the line 
of least resistance, it will pass into the posterior nares. This pro- 
cedure renders it possible to cleanse the nasopharynx thoroughly. 
The spray will insure more thorough cleansing than the douche, 
as the cleansing solution by this procedure can be brought in con- 
tact with the entire mucous-membrane surface ; while in the douche 
the direction of the current is influenced by the structures of the 
nasal cavity, and cleanses only that portion in direct line of the 
current. Sass's tubes can be used anteriorly or posteriorly. These 
are made of glass or hard rubber. 

Of the many atomizers I have tested, I consider that made 
after the suggestion of Bergson and modified by Llewellyn the 
best (Fig. 32), and use it in my private and hospital practice. 




Fig. 32.— Llewellyn's modification of Bergson's atomizer. 



A much simpler method of cleansing the nasal cavities, both 
anterior and posterior, is by means of the Bermingham nasal 
douche. 

In the use of the nasal douche care should be taken that the 
solution is not drawn into the Eustachian tube, as in some cases 
the bony wall is so formed that the current flows directly toward 
the Eustachian orifice ; such patients should not use any form of 
nasal douche. The fluid should be allowed to flow through 
the nasal cavities rather than forcibly drawn through, there- 
by lessening that danger. The repeated and long-continued 



ILLUMINATION AND EXAMINATION. 



47 



use of any solution, even by means of the douche or atom- 
izer, should be carefully guarded against, as the nasal 
mucous membrane requires the same rational treatment as is 
necessary in the treatment of any other disease. As the disease 
process goes on to recovery, the solution should be modified in 
strength or discontinued ; otherwise the mere use of the solution 
may keep up inflammatory action. 

If the postnasal space cannot be thoroughly cleansed by the 
methods described above, excellent results can be obtained by 
using the postnasal syringe, which is a common barrel syringe, 
fitted with a curved tube perforated at the end, which sends jets 




Fig. 33.— The Bermingham nasal douche. 



in every direction. This can be used either for the nose or 
pharynx. 

After the atomizer and douche another instrument is necessary, 
despite many well-known authors to the contrary. This is the 
long, narrow applicator or probe (Fig. 34). The one which I 



Fig. 34.— Straight smooth applicator. 

prefer is of copper, especially hardened, but sufficiently pliable 
to be bent to any angle or curve desired, and should be made to fit 
the universal handle. After cleansing the parts by means of the 
douche, atomizer, or probe and cotton, the surface should be care- 
fully dried by means of cotton wrapped sufficiently tight upon 
the end of the applicator, to allow of thorough mopping. This 
will remove any crusts of dried secretion, or at least loosen them 
so that they can be removed with slight effort on the part of the 
patient. 

The nebulizer and the inhaler are indispensable articles, the 
advantage being that vapor will penetrate where fluids will not 
reach. In the nebulizer the remedial agent should be suspended 
in some bland oil which will adhere to the membrane, causing it 
to remain in contact for some time, as well as affording protection 
to the sensitive area. 



48 



DISEASES OF THE NOSE AND THROAT. 



The best appliance for the application of such solutions is the 
Globe inhaler or some modification of this instrument, the watch- 
case atomizer, or an ordinary dropper. 

A useful attachment to the nebulizer shown in Fig. 35 is the 



Cerent fnterrupl"? l/^tiim. 7 
I Valve 6 




ffottthf 



.Catheter Conn eel ion 

Fig. 35.— Six-flask Globe multinebulizer. 



hot-air apparatus (Fig. 36), which is employed in the treatment of 
lesions of the accessory sinuses and of the middle ear. It t per- 
mits the use of plain hot air, or hot vapor, or medicated vapor. 
In the acute lesions of the accessory sinuses, especially of the 




Fig. 36.— Hot-air apparatus. The space above the lamp is the hot-air chamber, through 
which the medicated air passes. The holder on top is for bottles, in which may be placed 
solutions that are to be heated. 



sphenoidal and ethmoidal, the hot vapor considerably allays the 
swelling and irritation by relieving somewhat the blood-pressure, 
although in the majority of cases the relief is more temporary 



ILLUMINATION AND EXAMINATION. 



49 



than permanent. In the treatment of acute inflammatory condi- 
tions of the middle ear, however, it is highly beneficial/ When 
simply hot air is used, the simplest apparatus is the one shown in 
Fig. 37. The degree of heat can be controlled and measured. 




Fig. 37.— Electric hot-air apparatus. 

An inhaler affording a simple and convenient method of appli- 
cation is Coulter's, which consists of a small spirit lamp, over 
which is fitted on the same stand a water reservoir, to the top of 
which is connected a bulbous tube. This tube is jointed at 
the bulb, and within the expansion is placed a sponge on which 
the solution to be inhaled is poured (Fig. 39). When the lamp is 
lighted, the steam from the heated water passes through the 
sponge and becomes impregnated with the medicament, any excess 
from condensation or oversaturation being collected by a little 
cotton placed in the wide-mouthed piece with which the tube is 
provided. In its use the patient places the mouth-piece directly 
in front of the face and inhales the fumes. 

A simple inhaler can be improvised with a pitcher of hot water 
in which the medicinal agent is placed. A towel is then folded 
and formed into a cone, or an ordinary tin funnel of sufficient size 
may be employed, and placed with the large end over this reser- 
voir, concentrating the vapor, and the patient directly inhales the 
fumes. 

An essential feature in office work is the thorough cleanliness 
of the instruments used. This can be accomplished by steam 
sterilization and by the use of antiseptics. The Lewis electric steril- 
izer (Fig. 38), or the steam sterilizer, as shown in Fig. 40, which can 

4 



50 DISEASES OF THE NOSE AND THROAT. 

be placed on a table and kept constantly heated by means of a very 
small flame, permit of rapid sterilization. At the same time the 




Fig. 38.— Lewis' electric sterilizer. 



separate compartments admit of having always on hand boiling 
water. Besides the cleansing of the instruments by heat, they should 

be dipped in absolute alcohol 
and aqueous extract of hamam- 
elis, equal parts — a combination 
that removes any objectionable 
metallic taste. Instruments used 




Fig. 39.— Coulter's inhaler. Fig. 40.— Ferguson's sterilizer. 

in routine examination should be thoroughly disinfected after each 
usage. It would be well to have of the instruments most com- 
monly used — that is, the tongue-depressor and nasal speculum — a 
number of duplicates, thus enabling the practitioner to use for 
each individual a separate instrument. 



CHAPTER III. 

GENERAL CONSIDERATION OF MUCOUS MEMBRANES, 
THEIR PATHOLOGICAL CHANGES, AND RELATION 
TO GENERAL MEDICINE. 

The term " catarrh " as generally used implies much ; liter- 
ally it means " to flow downward." It is popularly used in desig- 
nating all varieties of mucous-membrane inflammation of the 
nares, whether acute or chronic, hypertrophic or atrophic. Ap- 
plied to any of these conditions the term is a misnomer, as the 
catarrh is merely a symptom. I therefore shall not use the word 
" catarrh," but, in its stead, a term which will describe the exist- 
ing pathological condition. It is proper, however, to speak of a 
catarrhal inflammation, meaning that special condition in which 
secretion and elaboration of mucus are increased. 

In many constitutional diseases there is an increased exudate 
from the mucous membrane. This is brought about by inter- 
ference with the circulation, by vasomotor phenomena, and by 
alteration in the blood. It is also due to changes in internal organs 
whereby elimination is interfered with — as, for example, in dis- 
eases of the kidneys, when the skin and mucous membrane vicari- 
ously aid as eliminators. Congestion, acute or cyanotic, of internal 
viscera causes marked alteration in the mucous membrane, even 
of the larynx and pharynx. 

Intestinal irritation and chronic constipation may cause the 
pharyngeal and laryngeal mucous membranes to become thickened 
and congested, and even the veins to present a varicose condition. 
Diseases of the liver, kidneys, intestines, lungs, pleurae, heart — 
in fact, almost any serious inflammatory lesion — will be manifested 
in the mucous membrane of the upper air-passages by some altera- 
tion in its function due to circulatory changes, which, if continued, 
may produce structural alterations. 

These systemic conditions illustrate the importance of urinary 
examination on the part of the specialist as well as the general 
practitioner. 

Primary lesions of the accessory sinuses may give rise to true 
or apparent nasal lesions. The nasal discharge coming direct 
from the sinuses will produce secondary irritation of the nasal 
mucous membrane. 

It is a w T ell-known fact that in anemia there is edema, leakage 
of serum from the kidneys, and in some instances intestinal 
changes., as watery diarrhea. In these cases the respiratory mem- 

51 



52 DISEASES OF THE NOSE AND THROAT. 

brane will also show a thin, slightly albuminous, watery exudate. 
This is especially true in children, and is due in a large number 
of cases to the intestinal irritation set up by such parasites as the 
Ascaris lumbricoides. Such cases should not be confused with 
strumous rhinitis. 

The shape of the nostril has much to do with the so-called 
catarrhal diathesis. Not infrequently patients will say they have 
inherited catarrh, when, in fact, they have inherited the family 
nose — the narrow, slit-like nasal cavity, so straitened that the 
least congestion of the mucous membrane closes the nose by nar- 
rowing the lumen of the nares and lessening the size of the nasal 
cavities ; for, backed up as the mucous membrane is in this locality 
by bone or cartilage, it can distend in but one direction — that is, 
toward the lumen of the air-passage and away from its resistant 
background. The free passage of air and perfect drainage are 
interfered with, causing an accumulation of secretion, which by 
its presence irritates the mucous membrane and produces some 
form of rhinitis. 

The idea is quite prevalent, especially among the laity, that 
catarrh, as they state it, " runs into consumption." There is no 
doubt that long-continued catarrhal inflammation tends to weaken 
the tissue-resistance, and that a postnasal rhinitis with accumula- 
tion of secretion at night will cause pharyngitis, laryngitis, trache- 
itis, and bronchitis. The patient unconsciously swallows, at such 
time, some of the secretion, and this, collecting in the esophagus 
and stomach, will soon generate a catarrhal condition in these 
parts. The physiological resistance being lessened in this way, 
and the patient being possibly of a tubercular tendency through 
exposure to tuberculosis, he may develop th.e disease ; but disease, 
like tissue, never changes type ; it can only predispose. 

Too much importance cannot be attached to nasal breathing. 
Many cases of disease of the nose and throat necessitating mouth- 
breathing, if continued for any length of time, produce a marked 
effect on the general health. This is especially true in children, 
and should be corrected early. If interference is not prompt and 
effectual, the obstructed nasal breathing, with the continuance of 
the forced snuffling inspiration so often seen in these cases, may 
cause a drawing down of the facial muscles, not only changing the 
child's expression, but often, by the continued pressure, altering 
the contour of the upper arch by drawing in the upper jaw. The 
hard palate, instead of forming the perfect dome, is moulded into 
a high irregular arch. 

When the floor of the nose or superior maxillary bone is thin 
from deficient breathing in early childhood or from other cause, 
the terminal nerve-fi laments going to the root of the tooth course 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 53 

superficially along the floor of the nose, and in cases of deflected 
septum, where the deflection is close to the floor of the nose, with 
redundant tissue, an inflammatory process is set up which injures 
the nerve-roots and may cause devitalized teeth, or may ulcerate 
and produce a sinus discharging around the tooth, simulating 
pyorrhoea alveolaris. I have observed a number of such cases. 

The shape of the bony framework of the nose, especially the 
floor and the turbinated bones, will determine largely the drainage 
of the normal secretion, whether it go forward or backAvard, and 
will also determine the liability to accumulation of dust. This 
may explain in many cases the catarrhal tendencies. 

Frontal headaches and facial neuralgia in many cases may be 
entirely dependent upon nasal or accessory sinus-lesion. The 
relation of the nasal regions to affections of the eye will be men- 
tioned under a separate chapter. 

The changes produced in the blood are well shown in a series 
of blood-counts which I made in cases in which there was nasal 
obstruction, the counts being made before and after the removal 
of the growths. In every case before removal the red blood- 
corpuscles (the oxygen-carriers) were reduced to 3,000,000, in some 
instances as low as 1,500,000, with the hemoglobin reduced to 50 
or 60 per cent, of normal, and in many cases with slight increase 
of the white corpuscles. After removal of the obstruction both 
hemoglobin and corpuscles gradually increased to the normal. 

Occupation also causes mouth-breathing, as is seen in engineers, 
car-drivers, trainmen, motormen, and bicycle-riders. The tendency 
is to keep the month slightly open, and in many patients of these 
classes marked alteration in the mucous membrane of the pharynx 
and larynx will be found, due to irritation caused by the direct 
inhalation of dust. 

On the other hand, there is found a class of cases in which 
the altered condition of the membrane is due not to an external, 
but to an internal irritant, due to some perversion of the secre- 
tory and excretory functions. From a diagnostic standpoint the 
study of the saliva — sialosemeiology — is of the greatest import- 
ance, and in many cases the determining of the altered chemistry 
of this secretion will be of great value in diagnosis and treat- 
ment.- 

It is a well-known clinical and laboratory fact that a study of 
the products of the secreting organs, which in their excretory 
functions throw off waste material, gives us by deduction a fair 
idea of what process is going on within the body. Yet this excre- 
tory secretion or material is altered in its chemical composition 
and controlled by the chemical constituents within the body 
proper. There is no question that under certain conditions — for 
example, when the secretions are acid or alkaline — the chemical 



54 DISEASES OF THE NOSE AND THROAT. 

process taking place within the various secretory glands must 
vary, and the product of such variation in these unknown quanti- 
ties must be somewhat the same as the variations we would obtain 
in dealing in the laboratory with known compounds ; in other 
words, that the body is largely a chemical laboratory, having on 
hand a certain amount of material, and having added to it daily 
other ingredients through the respiratory and alimentary tract. 
Now, any perverted condition from what is known as the normal 
chemistry may bring about a series of changes and produce 
chemical products which may be harmless or productive of dis- 
ease-processes. On no other basis can we explain the various 
diatheses and the precipitation of certain materials in the tissues 
of the body ; for example, why uric acid should be formed and 
precipitated in so many and varied forms in certain individ- 
uals, while others are absolutely free from such chemical com- 
pounds. 

I devoted a number of lectures to this subject during my 
course on pathology in the Jefferson Medical College in 1895-96, 
being so impressed with the import of the study of not only the 
excretions from the intestine and kidney but also of the saliva 
and various secreting glands, carrying on, as time would permit, 
investigations in this line in my own private laboratory. 

That cell-nutrition depends upon the chemistry of its supply 
is illustrated in disease-processes associated with any form of in- 
fection or rise in temperature. This opens up an enormous field 
for speculation and investigation. The amount of infection, the 
peculiar chemical change produced by temperature, the materials 
absorbed into the body from infective processes, or the auto-infec- 
tion from the intestinal tract, would in each condition produce its 
own peculiar chemical compound. Yet I believe a general basis 
or standard can be reached, at least sufficiently accurate from 
which to draw chemical and clinical deductions. For an exam- 
ple of the peculiar effect on various structures in the body brought 
about by an altered chemistry, I will quote from an article published 
in American Medicine, February, 1902, in which I reported a num- 
ber of cases of enlargement of the thyroid gland in which the 
cellular elements of the thyroid structures were increased, the 
enlargement not being due to distended vessels, cystic condition 
of the gland, or new growth. I reasoned the matter out as 
follows : It is a well-known physiological and therapeutical fact that 
certain drugs have a selective action on certain tissues or organs 
of the body — e. g., belladonna with its selective action on the 
pharyngeal surface, sodium phosphate with its selective action on 
the liver, etc. It is also a physiological fact that the normal chem- 
istry of the body controls the normal secretions from the various 
secretory organs ; that any perversion from the normal necessarily 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 55 

alters the character and chemistry of the secretion and that the 
products of such alteration act as irritants to certain parts of the 
body ; the difference between this and drugs administered is that 
one is introduced into the body and one is manufactured within 
the body. I therefore reasoned that under certain conditions 
there was precipitated (due to perverted chemical action) a certain 
material which, circulating through the blood, had a selective 
action on the thyroid gland, acting as an irritant to that gland 
and stimulating its blood-supply. While the treatment of these 
cases reported was largely empirical, I believe, however, that the 
drug introduced into the body by its chemical action altered the 
chemistry of the material which was acting as an irritant, either 
rendering that irritating material inert or forming a compound 
which was non-irritating. I was convinced that from the study of 
the saliva we could determine to a great extent any variation in the 
chemistry of the body. As these various secreting glands receive 
from the blood the supply from which they elaborate Certain 
chemical compounds, if an analysis be made of the composition 
of such secretion it would give a good index to the general condi- 
tion of the individual ; and while in many cases the deductions 
have to be based on, or rather associated with, clinical observa- 
tion, I soon found them to be of immense value from a standpoint 
of diagnosis. 

A few cases will serve to illustrate the import of the saliva 
from a standpoint of diagnosis. The first case in which I made a 
study was as follows : 

Mr. C, aged 42, consulted me in regard to what he supposed to be a 
catarrhal condition associated with ozena. His breath was most offensive, 
but, although pronouncedly so, it was not the penetrating, clinging odor ob- 
served in atrophic rhinitis with ozena. He had observed the condition rather 
suddenly, and it had existed continuously for some four or five years. His 
history was absolutely negative as to any catarrhal condition other than an 
occasional cold. He had consulted specialists both in this country and 
abroad, not only as to the possibility of the odor coming from the nose or 
some of the accessory cavities, but had also consulted specialists on dis- 
eases of the stomach, as well as having had a thorough inspection of all his 
teeth. He had been told that he had practically no catarrh, and as his 
digestion was good and nothing was found wrong by analysis of the con- 
tents of the stomach, the source of this odor was quite puzzling. After a 
thorough examination, and knowing that the men under whose care he had 
been were most thorough and competent in their line, I reasoned that there 
must be some source of the disagreeable odor outside of the parts already 
mentioned. As this was in the winter of 1895, and as my attention had 
been called to the import of the secretions by other conditions, as well as 
by a statement made to me by the patient, I decided to investigate the 
saliva. The statement which he made to me, which was most significant, 
was this : That while his appetite was very good, when his olfactory nerve 
was stimulated by the odor of a delicious meal, causing his mouth to water, 
the disagreeable odor and taste became so pronounced as almost to nauseate 
him. I then collected some of the saliva. The method I used for its col- 



56 DISEASES OF THE NOSE AND THROAT. 

lection I learned from my experience in a dentist's chair — that while sitting 
with your mouth wide open for a few minutes you have a most profuse flow 
of saliva. This method, practised just before meal-time, resulted in the col- 
lection of quite a large amount of the secretion. The oflfensiveness of the 
secretion was at once detected. Now, whether this offensiveness was due to 
a chemical reaction brought about by the mixing of the various salivary 
secretions and their exposure to air I am unable to say ; but one thing was 
certain, that when the secretion was collected and placed in a sterile bottle 
it at once demonstrated the source of the odor. After experimenting with 
a number of solutions I was able to demonstrate the presence of a sulpho- 
cyanid, which, with the ammonia salts, caused rapid decomposition. 

I have studied two other cases similar to the one quoted, in 
which the odor unquestionably came from the saliva. Another 
case was a peculiar form of leukoplakia, in which I believe the 
peculiar change brought about in the surface epithelium was due 
to some chemical compound formed from the salivary secretion. 
Four other cases which I studied were peculiar ulceration involv- 
ing the tongue, lips, and buccal mucous membrane. The ulcers 
resembled very much those associated with certain diseases of the 
stomach, and described as aphthous ulcers. The salivary secre- 
tion in each case was strongly acid, showing the lack of proper 
oxidation. Remedial agents directed toward the changing of the 
chemical reaction of the secretion speedily effected a cure in three 
cases ; the fourth patient is still under observation, but is much 
improved. 

My studies of the saliva have been very much in the same line 
as Michaels', although not so extensive, and the deductions are 
practically the same as he gives below : First, the study of the 
normal healthy saliva ; second, the saliva from hypo-acid indi- 
viduals ; and third, the hyperacid condition. He also investigated 
the function of the biliary principles and the presence or absence 
of these principles in the blood-plasma and in the salivary secre- 
tions. His investigations proved that many of the substances 
found in the saliva by chemical analysis could be traced to this 
source. This is significant,, as the presence or absence of such 
material would enable one to determine the presence of hepatic 
toxins. Michaels' investigations also showed that modifications 
of the saliva were in direct relation with constitutional diath- 
eses. 

As the tissues and secretions depend upon the blood-plasma, 
any dyscrasia, then, would modify the chemical composition of 
the body and produce local or general manifestations. According 
to Ducloux, hypo-acidity favors chemical changes in the tissues ; 
in hypo-acid conditions all the oxidation processes are exagger- 
ated ; and in hyperacid conditions oxidation is incomplete ; as a 
result, there is an increase in the quantity of organic acids. By 
the ordinary litmus test, blood is normally alkaline ; but, as 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 57 

Douin and Gautrelet have shown, if we study the distribution of 
the acids and bases of the blood-plasma we see that the reaction 
is really acid ; and if the acid waste products are not eliminated 
this acidity is increased. The secretions and excretions then be- 
come of an acid reaction. This is illustrated in certain of the 
chronic diseases in which we have a constant characteristic symp- 
tom in the increase of the acidity of the urine. 

The ammoniacal salts and sulphocyanid in healthy saliva are 
in equal proportion and in very small quantities; in the hypo-acid 
condition the ammonia exists in greater quantities than the sulpho- 
cyanid and tends readily to decomposition. In the hyperacid 
condition the sulphocyanid is in excess, and the tendency to de- 
composition is not so great as in the hypo-acid condition. 

The altered chemistry of the saliva presents many possibilities 
from an etiological standpoint. It is quite possible that many 
forms of indigestion and diseases of the stomach and intestines 
mav be brought about by the altered chemistry of the saliva. A 
great many morbid processes are traced to uric acid in some of its 
many forms, but I believe that many other substances equally 
important are deposited and eliminated, which substances act as 
irritants, not only causing stomach and intestinal diseases, but also 
explaining many of the so-called reflex neuroses — e. g., hay fever. 
It is a well-known clinical fact that saliva from certain individuals 
is exceedingly poisonous, as is indicated by the infectious wound 
produced by the bite of such individuals, showing that the saliva 
may be the site of poisonous pathological compounds as well as 
physiological compounds. It is quite probable that some of the 
so-called reflex diseases — for example, asthma — if the cause could 
be traced, would probably be found to be due to a perverted sali- 
vary secretion. 

Unquestionably the chemical reaction of the secretions of the 
body is an important factor in the susceptibility of individuals to 
disease. I think there is no doubt that the fact that at one time 
an individual resists disease and at another time succumbs, can be 
largely explained on this basis. To be sure, it is a question of 
resistance on the part of the individual, but that resistance is 
largely controlled by the chemistry of the cell or secretion. It 
also demonstrates the fact of the accumulative phenomena of cer- 
tain of the diseases, as is illustrated in uric-acid diathesis, which 
Haig has described as uric-acid storms. There is no reason why 
these same phenomena could not occur as the result of the accu- 
mulation of other materials, brought about by chemical changes 
which lessen oxidation and tend to precipitation and accumulation 
of various morbid products. 

The administration of drugs for the relief of, for example, 
an infective process, probably affects such a process beneficially, 



58 DISEASES OF THE NOSE AND THROAT. 

owing to the fact that in its action it changes the chemistry of the 
secretions and blood constituents, thereby producing a chemical 
compound which either prevents the formation of infectious mate- 
rial or alters the nidus of infection to such an extent that it is not 
suitable for the growth of bacteria. 

In determining the general condition of the individual as to 
the physiology of the secretions, examination of the urine is, of 
course, of great significance. However, in examination of this 
excretion we can determine only the condition of waste. We can, 
of course, draw certain deductions as to certain metabolic changes 
which produce the chemical products found in the urine. It 
seems to me, however, that in the examination of the saliva we 
can better determine the chemistry of the tissues. The salivary 
secretion, derived as it is directly from the blood, gives us the 
exact chemical constituents present in the system. This material 
is not only secreted and eliminated, but goes back into the system 
to produce certain other chemical and physiological changes. A 
study, then, of the saliva would give us a definite idea of what the 
system is elaborating, and from this material which goes back 
into the system we may be able to determine some of the effects 
produced in the system by it. In other words, as comparing the 
examination of the two fluids, one, the urine, is an excretion in 
which there is eliminated waste material, and is a physiological 
process ; the other, the saliva, is a physiological process in which 
there is secreted a physiological material, which after secretion is 
taken back into the system to serve a physiological and chemical 
purpose. Then from this secretion we surely can better deter- 
mine what physiological and pathological processes are going on 
within the body. 

Uric acid is not the only irritant produced by chemical patho- 
logical changes in the secretions. Excess of alkalinity may be 
just as irritating as an excess of uric acid. The individual in 
whom the chemistry of the secretion of the upper respiratory tract 
shows an excess of ammonia will unquestionably have irritated 
mucous membranes, and may present systemic symptoms almost 
analogous with rheumatism. In fact, from my own studies and 
observation, I believe that excessive alkalinity will produce symp- 
toms identical, although not as exaggerated, as those produced by 
the presence of uric acid. In these excessively alkaline cases the 
mucous membranes, especially of the upper respiratory tract, are 
more frequently affected than the synovial membranes of the joints, 
as is the case in the rheumatic condition. I have, however, seen 
instances in which the smaller joints were affected, and all the 
muscular symptoms of rheumatism were present, which was en- 
tirely due to the excessive alkalinity. 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 59 



INFLAMMATION. 

As the diseases of the mucous membranes are nearly all in- 
flammatory, before taking up the different varieties it is necessary 
to consider the structure of the membrane as well as its general 
and special inflammatory lesions. 

Mucous membrane consists essentially of three layers or parts : 
(1) Upon the surface, epithelial cells ; (2) a basement membrane 
upon which the epithelial cells rest ; (3) the submucous connective 
tissue, in which ramify the blood-vessels, lymphatics, and nerves 
essential to the life of the layers above (Fig. 12). The epithelial 
layer varies in two particulars — chiefly the character of the epi- 
thelium and the number of its layers. 

As a lining membrane of open cavities, it is essential that it 
should be soft, moist, and pliable. This is especially true of the 
nasal cavities, where the surface is exposed to the drying action of 
the air. The anatomical arrangement and physiological function 
of the mucous membrane fortunately counteract this tendency. 
The anatomy of the mucous membrane is the same wherever 
found, with slight variation as to function and layer of epithelial 
cells. Where the function of the epithelium is protective in char- 
acter, it is found in several layers ; where secretion is essential, 
there is usually but one layer. 

Where protective or propulsive force is needed, the epithelial 
cells are supplied with cilia, as in the bronchi and in the anterior 
nares. Epithelial cells possess the faculty of manufacturing from 
supplied nutrition new chemical compounds, as is seen in the secre- 
tion of the salivary glands, the gastric follicles, and the pancreas. 

Every mucous-membrane surface is, then, as it were, a labora- 
tory by which is elaborated material, of which the most constant 
is mucus. When altered by disease its physiological product is 
changed and does not serve its proper functiou, or it prevents the 
excretion of an agent for which the organism has no further use. 
The degree of this perversion of cell-activity largely controls the 
classification of mucous-membrane diseases. As cellular function 
is controlled by nutrition, and as the epithelial layer is dependent 
upon the subepithelial layer for its nutrition, any alteration in 
these substructures, local or constitutional, must necessarily affect 
the functional activity of the epithelial cells. The basement 
membrane consists essentially of two layers, one of which is 
always present, though both may not be demonstrable. The outer 
or genetic layer is composed of that part of the epithelium which 
reproduces the cells above ; this layer is absent in a few instances, 
in which, when the surface is deprived of epithelium, it re-forms 
from the margins. 

The connective-tissue layer of the basement membrane is con- 



60 DISEASES OF THE NOSE AND THROAT. 

stant. This layer is composed of fibrous tissue, and may have a 
scant supply of unstriped muscle-cells. 

The basement membrane varies in thickness. In the mouth 
and nose it is easily demonstrated, while in the alveoli of the lung 
it is almost invisible. Where changes in the size and surface of 
the organ occur, the basement membrane appears in irregular 
ridges. The nerve-fibers do not penetrate the membrane, the 
basement membrane being just beyond them, while the lymphatics 
open by stomata immediately beneath or into the genetic epithelial 
layer. 

The submucosa (the submucous connective layer), being the 
vascular layer, is the most important, and varies with location. 
In the anterior nasal fossae it is erectile, and where the tissue is 
subject to rapid alterations in surface, as in the stomach, it is espec- 
ially abundant. 

The function of the mucous membrane is to secrete mucus, to 
oifer an absorbent surface, and to afford a smooth, moist, pliable, and 
protective lining to the open cavities — that is, those communicating 
with the exterior of the body. The follicular and mucous glands 
secrete mucus, while at the same time the epithelial cells elaborate 
it. The rapidity with which fluids are absorbed is a physiological 
characteristic of mucous membranes. This action depends, with 
few exceptions, largely on the number of layers of epithelial cells. 

Inflammation of the Mucous Membrane. — Before giving 
the special inflammations of the mucous membrane, for the con- 
venience of the student inflammation in general should be con- 
sidered. 

" Inflammation is the aggregate of those changes which take 
place in any tissue as the result of an injurious action to which it 
has been exposed, providing the injury is not sufficient to devital- 
ize the part." 

Injury does not necessarily mean trauma, but may be direct or 
indirect irritation (toxins) — mechanical, chemical, or thermal, local 
or constitutional. In all acute inflammatory lesions certain changes 
or phenomena take place. These changes may be considered from 
two standpoints — the macroscopical or clinical, and the micro- 
scopical. 

The clinical phenomena are subjective and objective, and com- 
pose the five clinical symptoms — pain, swelling, heat, discoloration, 
and disordered function. 

The microscopical phenomena are demonstrable only under 
magnification, and may be briefly stated as follows : Dilatation of 
the blood-vessels, with increased flow and accumulation of blood 
in the parts, followed by a retardation of the current, due to 
lessened lumen caused by the adherence of the white corpuscles to 
the wall of the vessels, together with paresis and paralysis of the 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 61 

vessel. This condition, increasing, causes oscillation of the now 
sluggish current, followed by complete stasis. 

Previous to the stasis some of the liquid portion of the blood 
exudes into the perivascular tissue ; after stasis this exudation is 
more marked, and by an ameboid movement there is a migration 
of the white corpuscles through the walls of blood-vessels — the 
process known as diapedesis= If the inflammation is severe and 
sudden, there is also migration of the red corpuscles. This process 
is followed either by absorption of the exudate or by proliferation 
of the fixed connective-tissue cells and the migrated corpuscles. 
In the latter case, if nutrition is good, capillary budding takes 
place, and by the process of canalization the tissue is vascularized ; 
but if nutrition fails and the tissue is not infected, simple lique- 
faction-necrosis and absorption may occur ; if, however, the area 
be infected, suppuration will take place. 

All inflammatory conditions are divided into three stages : 

First Stage. — The change is in the blood, in its current, and in 
the blood-vessel walls — the intravascular stage, clinically the dry 
stage. 

Second Stage (Extravascular Stage). — Exudate of liquor san- 
guinis and migration of white cells ; clinically the wet stage, but 
more properly the exudative stage, as the exudate may be plastic 
(dry). 

Third Stage. — The terminative stage, depending on the condi- 
tion of nutrition and infection. 

These three stages are the constant phenomena of inflammation. 

By special inflammation is meant the phenomena that occur in 
various tissues, organs, or parts, or of a special disease or group of 
diseases. 

CLINICAL PHENOMENA. MICROSCOPICAL PHENOMENA. 



(1) Heat. 

(2) Swelling. First Stage 



(1) Contraction (?). 

(2) Dilatation. 

(3) Acceleration. 

(4) Accumulation. 

(5) Eetardation. 

(3) Pain. | (6) Oscillation. 

[ (7) Occlusion. 

(4) Discoloration Second Stao-e I (8) Exudation ( of Hquor sanguinis). 
{*) Discoloration. second stage ^ (9) Migration ( f corpuscles). 

/~\r\'jji> f (10) Termination — (a) by resolution ; 

(o) Disordered fane- TMrd gtflge I (6) by new . fo ; m ; tion . (c) b ^ 



tion. 



1 



suppuration. 



The second stage, as a rule, determines the variety of inflam- 
mation. 

The varieties of inflammation of mucous membranes that 
pathologically constitute special forms of inflammation, are : 1. 
Catarrhal. 2. Membranous — (a) croupous or pseudomembran- 



62 DISEASES OF THE NOSE AND THROAT. 

ous, (6) fibrinoplastic, and (c) diphtheritic. 3. Hemorrhagic. 4. 
Gangrenous. 5. Suppurative. 6. Chronic infectious. 

From these originate nearly all the varieties of rhinitis. In 
addition, there are the constitutional diseases, infectious fevers, 
etc., which cause many lesions of the mucous membranes, which 
properly come under one of the varieties above, differing slightly 
in cause and treatment. 

(1) Catarrhal Inflammation. — From a clinical standpoint 
catarrhal inflammations are divided into the acute and the chronic. 
Pathologically the conditions found are the resultants of processes 
usually acute to a greater or less degree, which merge into the 
chronic by a continuation of one of the stages of the acute variety 
or by repeated acute attacks. 

(a) Acute catarrhal inflammation of the upper respiratory tract 
may be due to a great variety of causes ; all of these causes, how- 
ever, produce the condition in one of two ways — by direct external 
irritation of the membrane, or by exerting their influence from 
the circulatory side of this structure. Of the factors that bear an 
etiological relation to this condition, infection is the most common. 
Catarrhal inflammation of the mucous membrane, especially of the 
upper air-passages, is either the concomitant or the sequel of such 
acute infectious diseases as measles, scarlet fever, typhus fever, 
diphtheria, and typhoid fever, while a similar condition will be 
found in the early stages of such chronic diseases as tubercu- 
losis and syphilis. 

After infection a large variety of causes may be grouped under 
the head of irritants, comprising exposure to cold, foreign bodies, 
heat in the form of either hot air or steam, irritating gases (such 
as chlorin, bromin, ammonia, sulphurous and osmic acid), poisonous 
escharotics (as the mineral acids, arsenic, etc., in sufficient dilution 
not to destroy the surface with which they come in contact), 
ptomai'ns, etc. Rapid thermal and barometric changes, excessive 
humidity, and sudden changes in atmospheric pressure (caisson dis- 
ease) are by no means uncommon causes, the inflammation being 
brought about by the alteration in the circulation and secretion, 
which is followed by a lessened normal resistance to the disturbing 
agent. This is practically true of all causes acting from without. 
Catarrhal inflammation may also be caused by a pure mycosis, as 
occurs in thrush. Pathological alterations in the lungs, kidney, and 
liver may be predisposing factors or even actual causes of the condi- 
tion. The same is true of rheumatism, gout, and allied conditions, 
as well as of intestinal irritation with obstruction to the circula- 
tion. Age is an important factor, the resistance of the membrane 
being at its maximum in adult life, while in the young and the 
aged it is most feeble. 

The above may not embrace all the causes of catarrhal inflam- 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 63 

mation of the respiratory tract, yet the majority not mentioned 
are subdivisions or closely allied to those given. 

It is important to remember in this connection that all mucous- 
membrane inflammations, of whatever type, have a catarrhal 
stage, just as cutaneous inflammations are associated with des- 
quamation. 

In the first stage of the inflammation the surface is dry, and, 
owing to obstruction of the muciparous glands brought about by 
the engorged vessels of the submucosa, is usually covered by a 
thin layer of tenacious mucus. This condition is soon followed 
by edema, due to the presence of the exudate in the submucosa. 
The tissue then becomes swollen, and when this occurs in the 
upper air-passages breathing is necessarily interfered with, the 
swollen membrane lessening the lumen and restricting the free 
passage of air. The color is an intense, almost dusky, red. 

The infiltration of the submucosa with serum and leukocytes 
follows close upon the engorgement of its vessels. The epithe- 
lium, being in this way deprived of its nutrition, becomes cloudy 
and swollen, and begins to desquamate. The voice becomes husky, 
at times even being lost, because of the lack of secretion brought 
about by this congestion of the submucous vessels. Xasal breath- 
ing is interfered with by the engorged erectile tissue, and a pecul- 
iar " nasal twang " is given to the voice, owing to the lack of the 
customary resonating space. 

This first stage usually gives way in a short time to an abun- 
dant secretion. Desquamation of the epithelial cells rapidly takes 
place, and the surface is covered with an exudate consisting of 
degenerated cells, including epithelial nuclei, leukocytes, and 
serum, the amount of fibrin and albumin present depending on 
the cause and severity of the inflammation as well as upon the 
condition of the blood. By the pouring out of the exudate and 
by the action of the lymphatics the infiltration in the submucosa 
is usually greatly lessened, and if the cause underlying the con- 
dition be removed, the circulation in the affected area will soon 
return to normal. The epithelial layer is re-formed from the 
genetic layer. 

As the basement membrane is rarely affected by inflammation 
of the acute catarrhal type, ulceration is not often seen. Should 
it occur, however, it will generally be found to be due to arterial 
thrombosis causing localized superficial death by coagulation- and 
liquefaction-necrosis. 

(6) Chronic Catarrhal Inflammation. — A series of acute in- 
volvements of the mucous membrane, due to the causes given 
above, often precedes inflammation of this type. More frequently, 
however, these acute attacks will be found as local manifestations 
of a persistent systemic affection such as syphilis, the slowed cir- 
culation of chronic heart disease, the blood-changes and vascular 



64 DISEASES OF THE NOSE AND THROAT. 

changes of Bright's disease, gout, rheumatism, and. malaria. Con- 
tinued local irritation, as by a tumor, will effect a similar result. 
Permanent alteration in the tissue will result from the infiltration 
of the submucosa by the leukocytes and serum. This embryonic 
tissue is produced by the proliferation of the migrated leukocytes 
and the fixed connective-tissue cells, which, if nutrition be ade- 
quate, goes on to organization and the formation of a fibrous 
structure which alters the nutrition of the submucosa by contrac- 
tion and impairs the functional activity of the mucous glands. 
The membrane is thickened and edematous in the early stage of 
the condition, because of the abundant exudate in the submucosa. 

By organization of this inflammatory exudate, together with a 
proliferation of the fixed connective-tissue cells, the so-called hy- 
pertrophic condition is brought about. Extension of the process 
by the contraction of the newly-formed submucous tissue, thereby 
lessening the blood-supply to the surface and altering the normal 
function of the membrane, with consequent shrinking and enlarge- 
ment of the lumen of the air-passage, merges it gradually from 
one of apparent hypertrophy to one of atrophy, a condition which 
has also been called " dry catarrh," because of the diminution in 
the secretion, due to the contraction above mentioned. Irrespec- 
tive of the original cause of the inflammation, should the secretions 
(usually dry and difficult of removal) be infected by the bacteria 
of decomposition, fetid and poisonous products will result, as may 
be seen in ozena and in chronic inflammations of the ear. 

(2) Membranous Inflammations. — In regard to the mem- 
branous inflammations there is much diversity of opinion. From 
a pathological standpoint they may be divided into : 

(a) Croupous or pseudomembranous inflammation, which is the 
lowest grade of membranous exudate, and is not due to any specific 
bacteria. The exudate, a highly coagulable albuminoid material, 
forms on the surface of the mucous membrane, and does not 
ulcerate nor organize. This condition may be produced by irri- 
tants (as chlorin and ammonia) or by escharotics which do not de- 
stroy the basement membrane ; it may also occur in infectious 
fevers, pyemia, and allied conditions. It is not necessarily limited 
to the upper air-passages, but may occur in the intestines or in the 
bronchial tubes — in fact, on any mucous membrane. The bacteria 
which are possibly etiological factors are the streptococcus (identi- 
cal with that found in suppuration and erysipelas) and Yon Hoff- 
mann's bacillus. 

(b) Fibrinoplastic inflammation, in which there is thrown out 
upon the surface a plastic material capable of organization, non- 
bacteric in causation, and in which the membrane tends to organize 
either in layers or in ma'ss, and is usually limited to the nares. 

(c) Diphtheritic Inflammation. — This variety, like all the mem- 
branous varieties, begins as a catarrhal inflammation. The exudate 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 65 

is of a low grade and is due to a specific germ, the Klebs-Loffler 
bacillus, or Bacillus diphtheria?. 

The diphtheritic poison produced by the germ induces, first, a 
death of the superficial epithelium and the leukocytes with which 
it comes in contact, followed by a change in the deeper cells of 
the mucosa. The second change is a coagulation-necrosis or 
hyaline transformation of the affected cells, the false membrane 
being an aggregation of dead cellular elements, nearly all of which 
have been transformed into hyaline material. That the foci of 
necrobiosis start from the epithelial surface and proceed inward is 
a distinguishing characteristic of diphtheria. 

The membrane forms on the surface as in any membranous 
condition, but on its removal a bleeding surface is exposed. This 
condition is due to destruction of tissue, or ulceration, and on 
further examination it will be found that this ulceration extends 
through the basement membrane, or that, the nutrition which 
necessarily comes from the submucosa being cut off, the area 
beyond, which is dependent upon it for nutrition, undergoes 
infective coagulation-necrosis with sloughing. In this variety 
of inflammation, should healing occur, fibrous-tissue formation 
and contraction will follow, with only partial, if any, re-formation 
of the epithelial coating. 

(3) Hemorrhagic Inflammation. — Inflammation of this variety 
does not often affect mucous membranes, but when seen is usually 
found accompanying processes virulently infectious, such as pyemia, 
septicemia, diphtheria, and anthrax ; it may, however, follow the 
application of a counterirritant, such as carbolic acid. It consists 
in a rapid inflammation, of the mucous surface, with hemorrhage 
into the interstitial structure. The capillaries supplying the area 
are blocked up, and the blood may even be poured out on the sur- 
face of the membrane. Should the area involved be small, it is 
likely that gangrene will result. The essential point of difference 
between this condition and simple purpuric interstitial hemorrhage 
is that the latter is absorbed without destruction of the mucous 
membrane, while in hemorrhagic inflammation destruction of tissue 
invariably takes place, with a resulting scar. 

(4) Gangrenous Inflammation. — Inflammation of this type is 
usually found in debilitated children, following one of the acute 
infectious diseases, most commonly measles. It may be due also 
to burns, scalds, or trauma of the mucous surface. An embolus 
cutting off the blood-supply to a limited area may give rise to 
the condition. The careless administration of such drugs as 
mercury, antimony, and arsenic may bear a causal relation. The 
inflammation may be the result of a hemorrhagic process, as 
before mentioned. The condition is common in diphtheria. 
Its mechanism is the same, irrespective of causation — i. e., the 
circulation supplying a certain area is cut off, and coagulation- 

5 



66 DISEASES OF THE NOSE AND THROAT. 

necrosis and gangrene result. Breaking down of the tissue follows, 
due to infection, be it primary, secondary, or multiple. Because 
of the fact that the submucosa is involved to a greater or less 
degree in all cases, the lymphatics are widely opened and absorb 
the toxic products of the microbic infection, which eventually 
gives rise to a condition of general septic intoxication. Hemor- 
rhage may result from the breaking down and infection of the 
obliterating thrombi blocking up the vessels. Bacteria (most often 
the streptococcus), entering the opened lymphatic pathways, may 
cause enlargement and even abscess-formation in the neighboring 
lymph-glands : or, should they effect an entrance into the blood- 
vessels, septicemia may result. Gangrenous inflammation is not 
often seen in the nose, but is common on the tonsil and in the 
mouth and pharynx. 

(5) Suppurative and Pustular Inflammation. — This variety 
of inflammation may occur in the course of septicemia, pyemia, 
chicken-pox, small-pox, or erysipelas of the mucous membrane, 
but is rarely seen in other infectious diseases. The formation 
of pus in the submucosa may be due to mixed infection in diph- 
theria. The submucosa may become infected by abrasion or de- 
struction of the protective epithelium, due to the fact that the over- 
lying structure offers more resistance than the glandular basement 
membrane. The pouring out of the infected contents of these 
glands into the submucosa results in distention and pus-formation. 
Suppurative tonsillitis and similar affections are caused in this 
way. Pus, being a product of connective tissue, develops in the 
submucosa, and secures egress by rupture of the basement mem- 
brane, through gangrene or ulcerative processes ; or the infected 
material may be disseminated by means of the lymphatics, as 
occurs in gangrenous inflammation. It is to be noted that sup- 
purative processes are, as a rule, found in those areas of the mem- 
brane most liable to injury or where numerous sulci afford easy 
lodgement for the infected material. 

(6) Specific Inflammatory Processes. — Synonyms. — Chronic 
infectious inflammations ; Specific granulomata ; Chronic specific 
inflammatory processes ; Infectious granulomata. 

Of the specific inflammatory processes there are six varieties : 
(1) Syphilis ; (2) tuberculosis ; (3) actinomycosis ; (4) glanders ; 
(5) leprosy ; (6) rhinoscleroma. 

(1) Syphilis. — The mucous membrane is commonly the seat of 
the primary lesion of syphilis. At its site the submucosa becomes 
infiltrated with small, round, epithelioid, and giant cells. By 
obliterative changes in the arteries the blood-supply to the surface 
is cut off, and ulceration ensues. These necrotic areas occur on 
the tongue, gums, cheeks, tonsils, palate, and pharynx. The ter- 
tiary lesion (gummata) of the mucous membrane occurs in the sub- 
mucosa, develops in the same manner as any other infectious 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 67 

granuloma, and passes through the same ulcerative process. When 
healing occurs, owing to the amount of fibrous tissue developed, 
marked contraction takes place, giving rise to strictures, usually 
presenting a characteristic stellate scar. 

(2) Tuberculosis. — As a rule, tubercular conditions of the upper 
air-passages are secondary to pulmonary lesions, yet primary 
tuberculosis of the upper respiratory tract is not a rare condition. 
The cause of tuberculosis, the tubercle bacillus, gains ingress to 
some portion of the mucous-membrane tract, and miliary tubercles 
develop around the vessels in the submucosa. With the destruc- 
tion of tissue and the enlargement of the tubercle, which is a 
homogeneous, non-vascular mass, the basement membrane and 
epithelium are deprived of their nutrition by the obliterative vas- 
cular changes induced, causing necrosis with ulceration. The 
basement membrane and the epithelial cells break down and an 
ulcer is formed. Through this opening the tubercular caseous 
material is discharged. Since the tubercular infiltration follows 
the blood-vessels, it is a natural sequence that the long axis of the 
ulcer is, as a rule, transverse to the long axis of the membranous 
tube, owing to the circumferential distribution of the vessels. Sur- 
rounding the area of ulceration new fibrous tissue may develop, 
which when contracting causes stenosis. 

(3) Actinomycosis. — This affection is common in the mouth, and 
is due to the ray fungus, or actinomyces. Abrasion of the mucous 
surface affords a nidus of infection which is usually introduced into 
the system by food containing the bacteria. The granulation- 
tumor which develops is similar in structure to the tubercle ; the 
surrounding zone of proliferating tissue usually resembles sar- 
coma. Sooner or later mixed infection occurs and suppuration 
follows. The finding of the ray fungus in the tissue or discharge 
determines the diagnosis. 

(4) Glanders. — This disease, which is caused by the Bacillus 
mallei, usually manifests itself in the nose in the form of ulcers 
resulting from the breaking down of the nodules which have formed 
in the submucosa in the same manner as in the preceding forms of 
inflammation. In the acute form gangrenous and septic conditions 
may occur. In the chronic form the ulcers resemble those due to 
protracted catarrhal conditions, tubercular or syphilitic disease, 
but are differentiated by the finding of the bacillus in the dis- 
charge. 

In the mucous-membrane surface from the overgrowth of the 
surrounding connective tissue and the extensive involvement of the 
submucosa, the resulting growth will clinically closely resemble 
sarcoma, as was shown in a case under the care of Dr. Emma 
Musson, of Philadelphia, in which the diagnosis was only estab- 
lished by microscopical examination and bacteriological investiga- 



68 DISEASES OF THE NOSE AND THROAT. 

tion, by which means the bacillus of glanders was clearly demon- 
strated. 

(5) Leprosy. — This variety of chronic infectious inflammation 
is rare in the upper air-passages, but occasionally may attack the 
nose and larynx, and is usually of the tubercular variety. The 
leprous nodule is formed like that of tuberculosis ; though 
ulceration does not always take place, pyogenic infection and 
breaking down may occur. The disease is due to the Bacillus 
leprce. 

(6) Rhinoscleroma. — This rare variety of inflammation mani- 
fests itself in a thickening and tumefaction of the nasal mucous 
membrane ; also the larynx may be the site of the lesion. Micro- 
scopically, the tissue appears to be allied to the round-celled sar- 
coma, though there are present certain small, highly-refracting 
hyaline bodies which form a characteristic element of the growth. 
The newly-formed cells do not present the finely-granular indis- 
tinct nucleated appearance met with in lupus and leprosy. The 
tumefied areas are at first red or pink and very tender, but later 
the tissue becomes white. The disease is believed to be due to 
the Bacillus rhino scleromatis, but the belief is by no means general. 
It is most common in Austria, Russia, and Central America, and 
is rarely seen in this country. It is essentially a chronic condition. 

NASAL BACTERIA AND THEIR RELATION TO DISEASE. 

Within the past few years there has been considerable investi- 
gation as to the import of bacteria present within the nasal 
chambers, and the relation of such bacteria as causal factors in 
disease-processes. Opinions differ as to the presence of pathogenic 
bacteria in the normal nasal secretions and in normal membranes. 
This raises the question as to what constitutes a normal nasal 
mucous membrane. While the membrane may be normal as to 
its function, yet the construction of the nasal cavity may be such 
as to permit of the accumulation of normal secretion within that 
cavity. This accumulated normal secretion forms a suitable nidus 
for the lodgement of dust and other irritating materials, which 
would soon cause local alteration, besides perverting secretion and 
being nutrient media for the development of bacteria, which are 
constantly being inhaled and find lodgement in the localized irri- 
tated areas. Inoculations from a nasal cavity in which, as regards 
structure, anatomical relations, and physiological functions, the 
tissue is what is called normal, in the majority of cases will show 
bacteria present ; however, unless the normal secretion has been 
retained and has undergone some chemical change, it does not 
form a suitable nidus or medium for the development of bacteria. 
Another important question which arises is the pathogenesis of 
the bacteria present. Although of the variety known as patho- 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 69 

genie, they may be non-virulent, and if the mucous membrane is 
not subjected to some irritation giving rise to lessened physiological 
resistance of the epithelial cells, these bacteria do not find a nidus 
for proliferation and are practically harmless. From my own in- 
vestigations, which include over 200 inoculations, I have been 
unable to draw any definite conclusions ; however, the surround- 
ings of the individuals have much to do with the presence or 
absence of bacteria, as well as the variety, found within the 
nasal chambers. For example, inoculations from nasal cavities 
which presented normal appearances, made under different sur- 
roundings, gave entirely different results. Repeated inoculations 
were made from the same individual, from the nasal mucous mem- 
brane, on rising in the morning, after staying in an office or room 
for several hours, after having been exposed to the street dust, and 
after having attended places of amusement. The results were as 
varied as though the experiments had been carried on in different 
individuals. Again, inoculations made from individuals having 
various forms of catarrhal inflammations of the nasal mucous 
membrane gave the same varied result ; however, in many in- 
stances I believe that the bacteria bore an important relation to 
the inflammatory conditions present, but that their etiological 
relation was secondary and not causal, and that before the bacteria 
found access to the mucous membrane there was some alteration in 
the epithelial surface, brought about either by external or internal 
irritants, which lowered the physiological resistance of the indi- 
vidual epithelial cells. Besides pathogenic bacteria, there are 
associated varieties of the blastomycetes, which, while not possess- 
ing any pathogenic properties, are capable of producing irritation 
and admit of absorption of saprophytic products. If the nostril 
is thoroughly cleansed under the strictest antiseptic precautions, 
and a pledget of sterilized antiseptic cotton placed within the nose, 
which in turn is protected by antiseptic measures, in the majority 
of cases the secreted mucus will be free from bacteria ; but from 
my own experience it is almost impossible to render the mucous 
surface thoroughly aseptic. As to the antiseptic properties of the 
nasal mucus, I am willing to grant that in certain individuals the 
secretion possesses such properties, depending upon the chemical 
reaction of the secretions — which differs in individuals — and it is 
largely controlled by the general health of the individual and by 
constitutional diathesis. In persons with irritated mucous mem- 
branes and with excoriations about the nasal orifice, whose nasal 
secretions and urine were decidedly acid, the bacteria present were 
non-virulent, and where growths were obtained on blood-serum they 
were feeble and slow of development. This can be explained by 
the fact that with few exceptions pathogenic bacteria require alka- 
line media. In diseases of the nasal cavities in which there is 
accumulation of secretion, as is the case in the various forms of 



70 DISEASES OF THE NOSE AND THROAT. 

atrophic rhinitis, the bacteriological examinations present such a 
variety of bacteria that no special one can be assigned as an 
etiological factor. Besides, there are always present the bacteria 
of decomposition — the saprophytic bacteria ; however, in such 
conditions it must be remembered that the products of these germs 
are constantly being absorbed from the mucous -membrane sur- 
faces, and in many cases may account for some of the ill effects 
on the general health of the individual, nearly always present in 
the advanced stage of disease. While the bacteria present may 
have largely lost their virulent properties, yet with suitable chem- 
ical constituents and reaction of the secretion, proliferation of the 
germ is favored and its normal virulence regained. Accumulated 
secretion in the nasopharynx and pharynx during sleep is fre- 
quently unconsciously swallowed by the patient. This infected 
material may bring about gastric disturbances, as is shown by the 
frequent association of gastric lesions with those of the upper 
respiratory tract ; however, this does not explain many of the 
associated conditions, but often, when such apparent relation 
exists, the local lesions were induced by and dependent upon 
some constitutional condition which brought about the lowered 
resistance on the part of the local epithelial structures. 

The bacteria found present on the nasal mucous membranes 
and in the secretion includes many of the pathogenic cocci and 
bacilli, besides many unclassified non-pathogenic germs. The bac- 
teria most commonly found are the staphylococci or micrococci, 
especially the Staphylococcus pyogenes aureus, citreus, and albus, 
the Micrococcus pneumoniae (Frankel), Bacillus tuberculosis, Fried- 
lander's pneumococcus, Klebs-Loffler bacillus, Von Hoffman's 
bacillus (bacillus of pseudodiphtheria), Bacillus foetidus, Loew- 
enberg's ozena diplococcus, and various forms of sarcina. Quite 
frequently the streptococcus is present, although in the ma- 
jority of instances it was associated with an acute inflammatory 
process. With this exception, frequently the isolated bacteria 
were not associated with any special inflammatory condition. 
The bacillus of diphtheria was found on the apparently healthy 
mucous membrane, after the individual had been exposed by pass- 
ing through the diphtheritic wards in the hospital, although there 
was no associated inflammatory process. Frequently the bacillus 
of tuberculosis was found present after the individual had been 
exposed to dusty air on the street, the inoculations being made 
from the nasal mucous membrane after one-half hour's exposure 
to the dust. While I do not mean to belittle the importance of 
bacteriological investigation, nor the important relation of bacteria 
to disease, yet I do believe that, in a great many cases of lesions 
of the mucous membrane of the upper respiratory tract, the part 
played by the bacteria is purely secondary. If the anatomical 
structure of the nasal cavities is such as to permit of accumula- 



GENERAL CONSIDERATION OF MUCOUS MEMBRANES. 71 

tions of secretions and dust, or the physiological resistance of the 
membrane is lowered by constitutional diatheses or organic lesions, 
the altered and accumulated secretion forms a suitable nidus for 
bacterial proliferation. 

Of the recent investigations in regard to nasal bacteria, the con- 
clusions given by Walter seem to cover the subject pretty thor- 
oughly, and are as follows : 

" The evidence seems indicative that the diphtheroids, particu- 
larly Bacillus segmentosis of Cautley, are concerned in the produc- 
tion of so-called common cold in its typical manifestations in the 
nose, and there is much evidence that it occurs in epidemic form. 
The Micrococcus catarrhalis is much more general in its manifes- 
tations, and is probably also epidemic and productive of a rather 
more severe inflammation, though mild epidemics occur. It seems 
likely that the symbiosis of these two organisms increases the 
virulence. The pneumobacillus of Friedlander is much more con- 
cerned in chronic conditions, and is probably identical with the 
ozena bacillus. The pneumococcus of Frankel flourishes in any 
part of the respiratory tract, and when virulent has been found in 
pure culture. Clinically, the segmentosus infection is most likely 
to be in the nose, seldom in the trachea, but may cause otitis media. 
Micrococcus catarrhalis is most apt of all to invade the larynx and 
trachea, but may occur in the ear or nose and with variable viru- 
lence. The pneumobacillus is mostly confined to the nose and 
sinuses. Influenza is conspicuous by its absence. Pyogenic cocci 
are non-pathogenic locally, except as secondary invaders, and the 
probability is that only a limited number of strains are concerned 
in causation of acute infections on the mucosa, and these are not 
genuine coryza." 



CHAPTER IV. 
DISEASES OF THE ANTERIOR NASAL CAVITIES. 

TAKING COLD. 

Acute Inflammatory Diseases. 

Acute Khinitis. 

a. Simple Acute Khinitis. 

a. Acute Khinitis in Constitutional Conditions. 

1. Measles. 

2. Pertussis, or Whooping-cough. 

3. Scarlet Fever. 

4. Small-pox. 

5. Typhoid Fever. 

6. Rheumatism. 

7. Diabetes Mellitus. 

8. Diphtheria. 

9. Erysipelas. 

10. Scorbutic Rhinitis. 

11. Anemic Rhinitis. 

12. Scrofulous Rhinitis (Strumous). 

13. Caseous Rhinitis. 

14. Epidemic Influenza. 

15. Lithemic Rhinitis. 
b. In the Young. 

b. Membranous Rhinitis. 

1. Croupous or Pseudomembranous. 

2. Fibrin oplastic. 

3. Diphtheritic. (See Diphtheria.) 

c. Occupation Rhinitis (Traumatic). 

d. Hyperesthetic Rhinitis (Hay Fever). (See Neuroses.) 
e. Ulcerative Rhinitis. 

/. Edematous Rhinitis (Acute Edema). 
g. Phlegmonous Rhinitis. 

Taking Cold. — Before taking up the subject of Simple 
Acute Rhinitis, the term " taking cold" should be considered first, 
in a broad general sense. To be sure, everyone having a cold has 
an acute rhinitis, yet this should not be strictly classed under 
catarrhal diseases of the nasal mucous membrane. It is a well- 
known fact that certain individuals are predisposed to taking cold. 
That certain individuals are more susceptible depends upon a 
number of conditions ; their resistance may be below par, their 
secretions perverted, causing faulty elimination. 

Taking cold, then, implies more than a local condition. It may 
be dependent on constitutional conditions, either original or 
acquired. Certain individuals, under varied conditions, are more 
susceptible to cold at one time than another. At certain times a 
person may be exposed and yet not take cold, yet at another time 
without any apparent rhyme or reason, they take cold. This 

72 



TAKING COLD. 73 

cannot be explained on any other basis than individual systemic or 
constitutional condition. 

The lithemic condition, where the patient without any exposure 
whatever may suddenly develop a severe cold, is also classed under 
the ordinary term of " cold." This, however, is due to the faulty 
chemistry of the secretion, where the glands of the mucous mem- 
brane in pouring out their normal secretion, this secretion having 
been perverted, produce an irritating mucus which in turn in- 
flames and irritates the nasal mucous membrane, causing every 
symptom of a severe cold in the head. Individuals with rheu- 
matic, gouty, or lithemic diathesis are especially predisposed. 

Contagious and infectious diseases also render the mucous 
membrane sensitive and predispose the individual. This is illus- 
trated by the catarrhal conditions following all the infectious dis- 
eases of childhood, and, in fact, all infectious fevers ; frequently 
following the recovery from the original lesion the patient is for 
several winters very susceptible to cold. 

Digestive disturbances, torpid liver, constipation, faulty elim- 
ination due to a lesion of the genito-urinary tract, may be a sys- 
temic underlying etiologic factor. 

Fatigue, either physical or nervous, renders the individual very 
susceptible, and while this should be classed under constitutional 
conditions, yet the individual's general health may be good, but 
at the time of exposure his physical or mental exhaustion renders 
him more liable to take cold. 

Nasal irregularities and obstruction, rendering the mucous 
membrane sensitive, are also a predisposing factor. 

Persons with sensitive skin or sensitive areas are also very 
susceptible. Interference with the function of the skin, which may 
be due to chilling of the surface when a person is warm or over- 
heated, may predispose the individual to taking cold. When a 
portion of the body, especially the back of the neck or head, or the 
extremities, is exposed to draughts, the person is very likely to take 
cold. The exposing of the wrists and ankles in a great many is 
an exciting factor. 

Sudden changes of temperature and climatic conditions may 
act as local and systemic predisposing factors ; also sudden changes 
of temperature, from a hot to a cold room, or the reverse, are 
equally predisposing factors. 

Overventilated or illy ventilated rooms may predispose the 
individual to cold. Individuals living and especially sleeping in 
rooms heated by means of registers, in which there comes from 
the furnace dry heat charged with dust and irritating gases, owing 
to the irritating effect on the nasal mucous membrane, are ren- 
dered more susceptible to cold. 

Certain seasons render individuals more susceptible to taking 



74 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

cold than others. The spring of the year, when the individual is 
likely to change from heavy clothing to a lighter weight garment, 
is a decided predisposing factor. Occupation may predispose an 
individual to taking cold. 

Irritating vapors may cause the mucous membrane to become 
sensitive and render the individual much more susceptible. Dust 
and smoke may also be classed as predisposing factors. 

The automobile is an exciting factor. The face-ache, conjunc- 
tival irritation, and nasal congestion, which are brought about by 
the exposure to dust and facing strong wind • this continued con- 
gestion blocks up the accessory cavities and tends to congestion of 
the nasal mucous membrane, lessening its resisting powers and 
interfering with normal functions, thus predisposing the individual 
to taking cold. The same condition has been observed in railroad 
engineers and individuals who test the speed and vibration of 
engines. 

In many of the above-mentioned predisposing causes the pro- 
cess known as " taking cold " may be arrested in the early stages, 
if the cause can be removed before the congestion passes into the 
second stage of the inflammatory process. 

The treatment in a general way must be directed, first, to the 
underlying cause, and second, to the removal of the cause or cor- 
rection of the condition, whether it be local, mechanical, or consti- 
tutional. 

SIMPLE ACUTE RHINITIS. 

Definition. — An acute inflammation of the nasal mucous 
membrane, extending occasionally to neighboring cavities, as the 
pharynx, the larynx, and the lower air-passages, and also in a 
milder degree to the accessory cavities. This tendency to exten- 
sion is usually shown only after repeated attacks. It is character- 
ized in the early stage by tumefaction and dryness of the tissues, 
followed by a copious discharge due to a hypersecretion and 
elaboration of mucus with cell-desquamation, and with more or 
less nasal obstruction. It may be limited to one nostril. 

Synonyms. — Acute coryza ; Acute idiopathic rhinitis ; Acute 
nasal blennorrhea ; Acute nasal catarrh ; Acute rhinorrhea ; Ca- 
tarrhal rhinitis ; Cold, or Cold in the head ; Common sporadic 
catarrh ; Rhinitis catarrhalis ; Simple catarrh ; Snuffles. 

Etiology. — Predisposing Causes. — Chief among the predis- 
posing causes of acute rhinitis are the various manifestations of a 
lowered bodily resistance to the exciting causes, such as more or less 
extended confinement in unevenly or overheated rooms, lowered 
nervous tone, the so-called nervous temperament, prolonged mental 
strain, an enfeebled circulation, feeble activity of the sudoriparous 
glands, the absence of the natural protection of the head, as seen 
in baldness, and extreme physical fatigue. Certain malformations 



SIMPLE ACUTE RHINITIS. 75 

of the nasal passages, as deviation of the septum or stenosis, by 
misdirecting the air-current, thus causing it to act as an irritant, 
or a membrane below par as the result of repeated acute attacks 
or of a chronic condition, may also be mentioned as predisposing 
factors. In some cases heredity seems to play a marked part. 
This is due to the inherited condition, or function of the nasal 
cavities, which predisposes to the disease. Some chronic condi- 
tions, as hay fever, asthma, rheumatism, tuberculosis, and syphilis 
are predisposing agents. Clothing either not suited to sudden 
changes of temperature, deficient in amount, or lacking over sensi- 
tive areas will produce a similar result. Some persons exhibit a 
tendency to acute rhinitis, which can be classed only under idio- 
syncrasy. Thermic and climatic conditions have an important 
influence. Individuals living in low-lying districts and exposed 
to all extremes of heat, cold, and moisture, are more susceptible 
to acute rhinitis than those residing in higher and dryer altitudes. 
Sexual excesses exert a marked predisposing influence. The aged 
enjoy a comparative immunity from the affection. 

Exciting- Causes. — The chilling of the body, whether from 
exposure to draughts, wet feet, sitting in damp clothing, or sudden 
exposure to cold after leaving an overheated room, or from cold 
to overheated rooms, violent exercise, or the like are the most 
prominent of the causative agencies. Prolonged exposure to un- 
due heat, artificial or solar, is also given by some writers as a 
cause. Acute rhinitis occurs also as a concomitant condition in 
the onset of certain of the infectious diseases, notably measles, in- 
fluenza, and tertiary syphilis. The affection may occur in certain 
forms of gastric and intestinal irritation, or follow the sudden 
cessation of the discharge in a case of otitis, gonorrhea, or oph- 
thalmia. It may be due to the extension of an inflammation from 
the pharynx, larynx, conjunctiva, or the accessory cavities, an ex- 
acerbation of the chronic form of inflammation, or occur in 
connection with eczema or impetigo. Acute rhinitis occurs occa- 
sionally in epidemics, due probably to existing climatic conditions 
rather than to any specific germ. Hajek, however, has described 
a large diplococcus, the " Diplococcus coryzse," present at the on- 
set of the attack, but its causative influence is as yet unproven. 
Others suppose an organism to exist, which has an incubation- 
period of about two days. Whether the disease itself is conta- 
gious or not is as yet an open question, some claiming that it is, 
others that it is not, the latter citing the numerous failures to pro- 
duce the disease by inoculation with the discharge from a patient. 
There is much confusion, not as to what constitutes a simple rhi- 
nitis, but as to where the process ends. Some authors limit the 
process to what is strictly an acute coryza, but whether simple or 
associated, primary or secondary, it is the same ; its termination 
depending on its course, its association, its repetition. 



76 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

A very large proportion of cases occur in those whose occupa- 
tions expose them in a greater or less degree to the inhalation of 
irritants, mechanical or chemical. Such a list would include workers 
in irritant drugs, artisans employing chlorin, ammonia, etc., stone- 
cutters, cement- and bronze- workers, weavers, millers, threshers, 
and grinders of spices. Inflammation produced by such irritants is 
more properly classed under occupation or traumatic rhinitis. For- 
eign bodies introduced into the nose w T ill also excite an acute rhinitis 
in a short time, as will also the presence of certain tumors of rapid 
growth. The abnormal direction of the air-current striking against 
the membrane in an unnatural way, whether it be due to some 
structural alteration from trauma, morbid growths, or congenital 
defect, is also an exciting cause. Certain drugs, if given inter- 
nally in large doses, have an irritant effect upon the nasal mucosa, 
notably the prolonged administration of the iodids, and in some 
individuals the tincture of cinchona. Dry air from heaters or gas 
from the range or the stove may act as an exciting cause. The 
physiological resistance on the part of the individual largely con- 
trols the susceptibility either to predisposing or exciting causes. 

Pathology. — The pathology of acute rhinitis is essentially 
that of a simple catarrhal inflammation, a description of which has 
already been given in the chapter upon General Considerations. 
The membrane is swollen, dark red in color, the vessels injected, 
and during the early stage the surface is dry or glazed with a thin 
film of tenacious mucus. Following this there is an exudate of 
the blood-fluid into the submucous connective tissue, with mi- 
gration of the white cells, and escape to a greater or less degree 
of the red corpuscles. Simultaneously there is a discharge of 
serum upon the surface which is clear, limpid, laden with salines, 
and irritant to the surfaces with which it comes in contact. The 
epithelium, deprived to a large extent of its nutriment, becomes 
cloudy, swollen, dies, and is w T ashed off. The leukocytes pass out, 
and the serum, at first clear and limpid, through admixture with 
these corpuscular elements and mucus, becomes abundant, cloudy, 
and thick, and is described as mucous or mucopurulent according 
to the amount of cellular constituents present. Occasionally, if the 
inflammation be very severe, there may be small ecchymoses seen, 
or minute abrasions or erosions may occur. If the attack be un- 
complicated and end in recovery, the vessels gradually regain their 
tonicity, the extravasated elements are absorbed, the discharge 
upon the surface lessens and thickens, and finally ceases, the 
denuded epithelium is replaced by new cells arising from the 
genetic layer of the basement membrane, and the membrane then 
returns to the proper performance of its normal function. 

Symptoms. — The attack is usually preceded by a general 
feeling of lassitude and discomfort, and if severe, with aching 
pain in the limbs and back. There may or may not be an initial 



SIMPLE ACUTE RHINITIS. 77 

chill. Generally there is more or less sneezing. Soon there fol- 
lows an oppressive sense of stuffiness in the nose, with obstruction 
to breathing and a dull, throbbing frontal headache over the site of 
the sinuses. The senses of smell and taste are impaired, and often 
that of hearing as well, due to involvement of the Eustachian 
orifice. The voice acquires an unaccustomed nasal twang. On 
inspection the nasal membrane is found swollen, dry, or glazed, 
and the nasal passages almost or quite occluded. The malaise 
increases, the skin is dry and becomes hot ; thirst, anorexia, and a 
furred tongue may be present. The nasal discharge, at first absent 
or scanty, becomes abundant, clear, and irritating from its excess 
of salines. There is more or less sneezing, the patient is obliged to 
use his handkerchief freely, and this with the irritant discharge 
gives rise to excoriation of the nasal alse and the upper lip. The 
alse of the nose are swollen, the eyelids are turgid, and there is ex- 
cessive lacrimation, with perhaps some photophobia. The dis- 
charge on declining may show a tendency to gravitate, the patient 
finding the lower nasal chamber filled with it on arising, while the 
upper chamber is clear. There is interference with proper masti- 
cation and deglutition, and the food, mixed with an undue amount 
of air from the necessitated mouth-breathing function, causes an 
uncomfortable sense of fulness after eating, which is soon relieved 
by eructation. The nasal discharge becomes thicker and more 
opaque as the second stage progresses, and the corpuscular 
elements increase in number. In severe cases constipation de- 
velops, and the urine becomes high-colored. There may be a 
moderate fever. Toward the close there may be an intercurrent 
attack of labial herpes. 

During the second stage inspection shows a swollen membrane, 
intensely red, injected, and covered by the characteristic mucous or 
mucopurulent material. The second stage shades imperceptibly 
into the last, and if the termination be in recovery the symptoms 
abate. The discharge becomes thicker and scantier, and may even 
crust or become infected by saprophytes ; the swelling subsides, 
the constitutional manifestations lessen and disappear, the special 
senses return to their normal state, and by a week or ten days the 
attack is usually over. It must be borne in mind, however, that 
this description applies to the typical so-called " idiopathic " form, 
the " cold in the head " of popular nomenclature. Acute rhinitis 
due to irritants, etc., as a rule, runs a shorter course, lacks the con- 
stitutional symptoms, and ceases usually after the withdrawal of 
the cause and the establishment of a free discharge. 

In speaking of the establishment of drainage, I am reminded 
that this flow from the anterior nares or from the posterior nares, 
or both, is dependent on the direction in which the turbinate bone 
or floor of the nose directs the flow from above — i. c, from sinuses 
or mucous membranes. In some cases considerable postnasal drip- 



78 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

ping or discharge is due to the backward tilting of the turbinates, 
directing the mucus flowing from above backward instead of for- 
ward. 

Diagnosis. — Usually no difficulty attends the recognition of 
acute rhinitis, its symptoms being so constant and, as a whole, 
pathognomonic. The greatest care must be taken, however, in 
diagnosticating to search for symptoms of other severer maladies 
in the symptomatology of which acute rhinitis occupies a promi- 
nent place. 

Prognosis. — As a rule, the prognosis is favorable ; less so 
perhaps in the aged. Various complications may arise, or the 
condition itself may become a chronic one through repeated 
attacks due to continuation of the irritant, which may be acting 
from without or manifested from within the body. 

Complications. — The complications of acute rhinitis, as a 
rule, are not serious, and are so constant in well-marked idiopathic 
cases as to be classed under symptoms. Extension of the inflam- 
matory process to the accessory cavities, which may become acutely 
suppurative, temporary occlusion of the nasal and aural ducts with 
consequent epiphora and perverted audition, acute conjunctivitis, 
pharyngitis, laryngitis, otitis, which may become suppurative, and 
labial herpes which may be the starting-point of a facial erysipelas, 
are mentioned as possible complications, only that they may be 
anticipated and avoided by proper prophylactic treatment. 

Treatment. — The treatment of acute rhinitis depends on the 
severity of the attack, the condition of the individual, as well as 
upon how far the inflammatory process involving the nasal mucosa 
has progressed. Unfortunately the patient rarely presents himself 
for treatment in the first stage of the affection. However, if the 
opportunity is afforded, much can be done to abort an attack. 

The blood-vessels in the submucosa in the first stage of the 
process are engorged. By the presence of this engorgement the 
ducts of the secretory glands are occluded, giving rise to dryness 
of the surface, the swelling being due largely as yet to the 
engorged vessels. The depletion of these vessels may be brought 
about in one of two ways, either by hastening exudation or by the 
use of remedial agents which, by their action on the nerve-fila- 
ments controlling the peripheral vessels, will cause contraction and 
thereby depletion. 

If the former plan be followed, there should be placed in one 
or both nostrils, depending on the involvement, a tablet con- 
taining ^ grain of sodium chlorid. This should be allowed to 
remain in position until completely dissolved. Its dissolution 
will be followed by a copious flow of mucus and serous exudate, 
leaving the membrane pale and relaxed. This should be followed 
by the application of an agent that will protect the membrane. 
For this purpose there is nothing better than a balsam preparation 



SIMPLE ACUTE RHINITIS. 79 

or an oily solution. If a slight astringent action is also desired, 
there should be applied to the membrane, by means of cotton and 
probe, a solution of equal parts of the compound tincture of ben- 
zoin and 50 per cent, boroglycerid. If protection merely is wanted, 
there should be dropped into the nostril a few drops of the fol- 
lowing solution every two hours, continuation depending on the 
relief afforded : 

3^. Olei cassia?, 

Olei santali, act gtt. vj (.36) ; 

Alboleni (liquid), fl^j (30.). 

If depletion by contraction is desired, there is nothing better 
for the purpose, notwithstanding the objection to the reactionary 
relaxation, than a weak solution of cocain ; 4 per cent., as a rule, 
will suffice. Personally, I insist on making the application of 
this drug myself, thereby lessening the danger of creating the 
cocain-habit by placing in the hands of the patient one of the 
most dangerous drugs. 

The following prescription may safely be given to the patient 
to use — two or three drops in each nostril night and morning : 

3^. Cocaine gr. ij (.12) ; 

Camphorse, gr. j (.06) ; 

Ol. rose geranium, gtt. ij (.12) ; 

Liq. albolene, n^j (30.).— M. 

If goocl results are to be obtained from the cocain, it must be 
used at least every three hours for not more than four applications. 
The frequency of treatment necessarily lessens the practicability 
of the procedure, as it would only be singers or public speakers, 
who depend on their voice for their livelihood, that would resort 
to the physician for such prompt relief. 

Heat applied in the form of a partially-filled hot-water bag, or 
the frequent application of a towel wrung out in hot water, or hot 
air applied by means of the apparatus as shown in Fig. 30, will 
relieve the disagreeable frontal headache due to the engorgement 
of the frontal sinus secondary to the nasal congestion. A simple 
and often effective procedure for the relief of this engorgement is 
to lean over the bath-tub or basin and dash into the face and nos- 
trils water as hot as can be comfortably borne. The application 
of a 6 per cent, suprarenal gland solution or 1 : 10,000 adrenalin 
chlorid has been favorable at times, but personally my experience 
with the drug has not been sufficiently satisfactory to warrant its 
use in all cases. 

Internally the administration of a purgative is advantageous. 
This should be given although there is no tendency to constipa- 



80 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

tion, the object being depletion through the intestinal tract 
Besides the depletion, the intestinal tract will, in this way, be 
rid of any irritants or sources of auto-intoxication which in them- 
selves might be causes predisposing to the attacks of coryza. If 
the patient can remain indoors during the day, or if he is seen in 
the evening, the administration of a 10-grain Dover's powder will, 
by its diaphoretic action, materially aid in the relief of the nasal 
congestion. This should not be given unless the patient will 
remain indoors at home. If the attack is ushered in by the more 
marked constitutional symptoms, there should be administered 
every three hours, until four doses have been taken, 5 grains 
of bromid of quinin. This should be followed by a warm drink, 
preferably a hot lemonade. Equally as good results can be ob- 
tained in this way as by a Turkish bath or by the hot-air bath, 
and there is less danger of evil after-effects. The patient should 
not be confined to his bed or even to his room, unless from the 
severity of the attack involvement of the accessory sinuses or the 
middle ear is threatened. 

Frequently it is impossible for the patient to be confined to his 
house, and usually his symptoms are not sufficiently alarming to 
justify such a course. In such cases admirable results can be 
obtained by the use of the following : 



. Pulveris camphorse, 


gr. J (.03) ; 


Extracti belladonna?, 


gr. i(.007); 


Quininse bromidi, 


gr.j(.06). 


. et fiat capsula No. j. 





This should be given every hour for three or four doses, or until 
the patient notices the physiological dryness in the throat, when 
the administration should be stopped for some three or four hours. 
The patient should also be instructed to drink plenty of water with 
the taking of each pill or tablet. In cases of cold due to exposure 
alone and with its manifestations limited to the nose, the fol- 
lowing, if used early and in proper dose, usually aborts the pro- 
cess. There should be given every hour 5 grains of the modified 
official compound morphin powder (Tully's) in which there has 
been substituted for the morphin 1 grain of codein. This does 
not have the disagreeable nauseating effect of the morphin. This 
preparation should be given in 5-grain capsules every hour for 
three or- four doses, the last dose taken at bedtime with a hot 
lemonade. 

In the second stage, or the stage of profuse exudation, very lit- 
tle can be done for the immediate relief from the secretion, as the 
process is going on to a resolution in the natural course of an 
inflammation. However, something can be done to prevent block- 
ing up of the nostril by the profuse secretion. There should be 



SIMPLE ACUTE RHINITIS. 81 

used through the Berroingham douche an alkaline solution consist- 
ing of 10 grains of biborate and bicarbonate of soda to the ounce 
of water, or, what is still more soothing to the membrane, tepid 
milk to which has been added 8 grains of sodium chlorid to 
the ounce. This should be followed by inhalations of benzoin 
with oil of tar, placing a tablespoonful of the compound tincture 
of benzoin with a fourth of a teaspoonful of the oil of tar in a 
vaporizer, as shown in Fig. 39, or an ordinary cup, or any wide- 
mouthed vessel ; there is then poured in the vessel a half-pint 
of water, which should be almost at the boiling-point. The cup 
is held so that the patient may inhale the fumes rising from it. 
Should the secretion be very profuse and thin with a prolongation 
of the second stage, astringents may be employed. For this pur- 
pose a 2 per cent, formalin solution will give admirable results, 
despite the pain arising from the application. Equally as good is 
the 2 per cent, solution of chlorid of zinc. If astringents are 
resorted to, there should be applied to the membrane, beginning at 
least four hours after the application of the astringent, the follow- 
ing : 

^. Olei eucalypti, gtt. ij (.12) ; 

Olei cassiae, gtt. iv (.249) ; 

Alboleni, fl^j (30.00). 

The patient should be instructed to apply by means of an ordi- 
nary medicine-dropper a few drops of this solution into the nos- 
tril every few hours. As to the repetition of the astringents, the 
effect of a given application must determine. A good cleansing 
solution as well as astringent is : 

!fy„ Extract! hamamelidis (aqueous), fl^j (30.) ; 

Extract! hydrastis (aqueous, colorless), fl^iv (15.); 
Aquae destillatae, q. s. ad fl^ij (60.). — M. 

Sig. — A few drops in each nostril two or three times daily. 

Internally during this stage, especially in cases in which the 
constitutional symptoms continue, good results can be obtained 
from the following : 

1^. Ammonii chloridi, 3ij (7.5) ; 

Tincturae opii deodorati, gtt. xl ad lx (2.4-3.) ; 

Sacchari, 3iv (1 5.) ; 

Aquae camphorae, q. s. ad flsiij (90.). — M. • 

A teaspoonful should be administered every two hours for four 
doses, and repeated once every three hours as long as the symp- 
toms demand it. If, after the relief of the profuse exudate, there 
should be a tendency to bogginess of the membrane, 20 per cent. 



82 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

chromic acid solution should be applied to the swollen membrane. 
Before applying the chromic acid the tissue should be thoroughly 
wiped dry by means of a cotton-covered probe, and this followed 
by a 4 per cent, solution of cocain. After allowing the cocain to 
evaporate thoroughly, the membrane is again dried and the 
chromic acid applied. The object of drying the surface is that 
the acid may not be diffused over the surface. In applying the 
acid a very small piece of cotton should be tightly wrapped on 
a thin, fine-pointed probe. This should be dipped in the acid, 
the excess removed by drying with another piece of cotton, and 
instead of mopping the surface with it, the probe should be drawn 
in straight, parallel lines over the turbinates. 

The best method of preventing the threatened involvement of 
the accessory sinuses is relieving the nasal engorgement. This can 
be done by puncturing the nasal membrane by means of a sharp- 
pointed bistoury, which will relieve the local congestion. Ano- 
dynes should be pushed and thorough purgation insisted on. 
Heat should be applied externally and the nostril sprayed with 
water as hot as can be borne. Should the Eustachian tube become 
involved in the catarrhal process, the secretions collected within 
the tube should be drawn off by means of the Eustachian catheter 
and suction-apparatus, care being taken to use no inflation. Should 
examination of the urine, in an individual subjected to repeated 
attacks of acute rhinitis, show uric-acid tendency, the treatment 
should be directed toward the relief of the diathesis. Of the many 
alkalies used for this purpose, one of the best is citrate of lithium 
in 5- to 20-grain doses. 

In individuals who have collapse of the nasal orifices, in 
other words, a mechanical obstruction to the entrance of the nos- 
tril, such individuals invariably suffer with a certain amount of 
nasal irritation and catarrhal discharge. In such cases I have ob- 
tained excellent results from the use of nasal dilators in the form 
of a small nickel wire loop, graduating in size according to the 
nostril, and having the patient use this at night, placing it within 
the nostril on retiring, and removing it in the morning. Keeping 
this up for six weeks to two or three months has dilated the nasal 
orifices to such an extent that free nasal breathing is established, 
and it is a well-known fact that free nasal breathing is the best 
remedy for the relief of such catarrhal conditions. 

(A) Simple Acute Rhinitis in Certain of the Constitu- 
tional Diseases. 

Simple acute rhinitis occurs with varying symptomatic im- 
portance in several of the severer diseases. This is notably true 
in the following : 

Measles. — An acute coryza is one of the most marked symp- 



ACUTE RHINITIS IN CONSTITUTIONAL DISEASES. 83 

toms of the invasive stage of measles, and may be clue to the irri- 
tation of the nasal mucosa by the early eruption of the measles, 
similar to " Koplik's spots " in the buccal membrane. There 
are marked conjunctival injection, excessive lacrimation, and pho- 
tophobia, and with these are associated cough, a temperature 
rapidly rising to 102° or 103° F., and a characteristic drowsiness. 
There may be headache, nausea, and vomiting. The eruption of 
the rash about the fourth day clears the diagnosis. Ulceration 
of the septum is said to follow severe coryza in some cases. 

Pertussis (Whooping-cough). — Whooping-cough begins as a 
catarrhal inflammation of all the exposed mucous surfaces, and 
the patient has the symptoms of having taken a severe cold. 
Indeed, the conjunctivitis, photophobia, and pronounced nasal 
coryza, with its developing cough, may be so severe as to imitate 
strongly the onset of measles. 

Scarlet Fever. — The prominent catarrhal symptoms of the 
pharynx in scarlet fever are, except in the mildest cases, accom- 
panied by an acute catarrhal inflammation of the pituitary mem- 
brane, with a thin, acrid, watery, or corpuscular discharge. 

Variola (Small-pox). — The invasive stage of small-pox ex- 
hibits a marked involvement of the nasal mucosa with decided 
coryza and an associated conjunctivitis with epiphora and photo- 
phobia. The severe constitutional symptoms, initial rashes, and 
history of exposure should place the physician upon his guard. 

Typhoid Fever (Enteric Fever). — Congestion of the nasal 
mucosa is not uncommon during the progress of typhoid fever. 
This may be preceded by epistaxis. Coryza is a rare sequel unless 
associated with necrosis of the cartilage. 

Rheumatism, Acute Articular. — Acute rhinitis not infre- 
quently accompanies the commencement of the attack of articular 
rheumatism, due to the irritating action of the excessive uric acid 
condition, the mucous membrane aiding in elimination. 

Diabetes Mellitus. — I have seen two cases of diabetes 
mellitus in which the acute coryza present was apparently due 
to no influence beyond that of the constitutional condition. Each 
attack of rhinitis was apparently controlled by the presence and 
amount of sugar in the urine, the attack of coryza diminishing as 
the amount of sugar lessened and returning with its increase. 
Violet also reports a case in which the nasal mucosa was soft and 
bled at the slightest irritation. It resembles fungus tissue. In 
another, there were recurrent throat disorders lasting for long in- 
tervals ; the tongue was also coated. In one patient there were 
yellowish tumors on the turbinals and on the septum. All the 
patients had diabetes. 

Diphtheria. — An acute simple rhinitis occurs very commonly 
in diphtheria. Usually it heralds the extension to the nasal cham- 



84 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

bers of a precedent diphtheritic process of the oropharynx and naso- 
pharynx, and the symptoms of a nasal diphtheria soon supervene. 
In cases, however, in which the diphtheritic infection occurs 
primarily on the nasal membrane and the inflammatory swelling 
obscures inspection, the catarrhal symptoms may lead to the diag- 
nosis of a severe coryza, the real nature of the case being unsus- 
pected. In certain cases a catarrhal process may be substituted 
for the formation of a membrane. In cases of severe coryza the 
glands at the angle of the jaw should be examined for enlarge- 
ment, and the intensity and character of the constitutional symp- 
toms be taken into account. When no membrane is formed in 
the nose after the disease is well advanced, the nasal inflamma- 
tion will continue, caused by the absorption and presence of toxins 
in the blood. 

Erysipelas. — An acute rhinitis is sometimes seen accompa- 
nying a primary infection of the nasal cavities by erysipelas. The 
inflammation is very severe, the membrane extremely swollen, and 
there is a marked tendency to extension of the process to the nasal 
duct and the cutaneous surfaces. 

Scorbutic Rhinitis. — An inflammatory condition of the nasal 
mucous membrane with excoriation about the nasal orifice is not 
infrequently seen in infantile scurvy. 

Anemic Rhinitis. — Anemic rhinitis is a non-inflammatory 
condition of the nasal mucous membrane, characterized by en- 
gorgement of the vessels of the submucosa with the discharge of 
a clear exudate, and is unattended by any of the symptoms of 
acute rhinitis. It may occur at any age. 

While this condition is non-inflammatory, it properly comes under constitu- 
tional lesions with local manifestation. 

Etiology. — The nasal mucous membrane in anemic individuals 
presents much the same condition as the mucous. membranes of the 
other functionating organs. There is no local irritation, but with 
the generally bad nutrition and muscular relaxation the blood- 
vessel walls of the submucosa relax and allow leakage ; not alone 
from the arterioles, but from the lack of vessel-tone the circula- 
tion is slowed, and there is a certain amount of venous stasis 
followed by effusion. This is true of the kidney and intestinal 
mucous membrane in anemic individuals, and it would seem that 
a variety of mucous-membrane inflammation known as anemic 
were justifiable. These cases are not to be associated with the 
strumous variety. 

Pathology. — The surface of the membrane is watery, pale, 
and at the junction of the skin and mucous membrane the tissue 
is drawn or puckered in appearance. The cells undergo a watery 
infiltration and hydropic degeneration. The vessels not being 
backed up by muscular tissue readily fill with blood, but the 



ACUTE RHINITIS IN CONSTITUTIONAL DISEASES. 85 

tissue being relaxed and weakened by poor nutrition, there is a 
marked tendency to stasis, both venous and arterial. This, then, 
is followed by exudate or leakage into the tissue ; the epithelial 
cells, from poor nutrition and absorption of the exudate, undergo 
destruction by hydropic degeneration. 

Symptoms. — The individual presents the characteristic con- 
stitutional symptoms of anemia. The nasal membrane is coated 
with a thin exudate which at times is slightly irritating. There 
is little, if any, tendency of the discharge to dry on the surface 
and form crusts. There is slight blocking of the nasal breathing ; 
no odor. The discharge is continuous, and the greatest incon- 
venience to the patient is the constant use of the handkerchief. 
This anemic condition may be also present in the pharyngeal and 
nasopharyngeal mucosa, but not to such a marked degree. 

Treatment. — Local treatment other than a cleansing solution 
is of little avail. The general condition must be improved. In- 
ternal administration of iron, in the form of the peptomanganate, is 
advisable. The diet should be regulated. Strict attention should 
be paid to the bowels, correcting any tendency to constipation. 
Outdoor exercise is indicated. With improvement in the general 
health, the nasal symptoms will disappear. To accomplish this 
the active cause of the anemia must be sought for and the appro- 
priate remedial agent administered. For example, if the patient 
be a young girl suffering from anemia from menstrual disturb- 
ance, the treatment would be vastly different from that indicated 
if the anemia were due to rheumatism, kidney-lesion, or chronic 
malaria. The treatment must be directed toward the special causal 
factor. 

Scrofulous Rhinitis. — Synonyms. — Tuberculous rhinitis ; 
Strumous rhinitis ; Scrofulous ozena. 

Scrofulous or strumous rhinitis is not a local condition, but is a 
local manifestation of a constitutional diathesis, and occurs in 
poorly-nourished children, especially of the peculiar lymphatic 
temperament having the inherited tendency which predisposes 
them to tuberculosis. Indeed, it is nothing more than one of 
the manifestations of the initial stage of tuberculosis, which under 
favorable conditions with proper hygienic and constitutional treat- 
ment may be relieved, or may progress to an actual tubercular 
infection, bearing the same relation to tuberculosis as Paget' s dis- 
ease of the nipple does to carcinoma. Scrofulous rhinitis is 
usually associated with enlargement of the cervical, submaxil- 
lary, and sublingual glands. There is a characteristic anemia, 
with the pinched face giving an expression almost as of one suf- 
fering pain. The orifices of the nostril are usually excoriated, and 
there is tendency to crust-formation with accumulation of secretion 
high up in the nostril. There may or may not be odor. To the 
sense of touch, the nose, especially the cartilaginous portion about 



86 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

the orifices, has a leathery feeling. The microscopic examination 
of the secretion shows no specific micro-organisms. Usually 
staphylococci and saprophytic bacteria are found. When, how- 
ever, if associated with these organisms the streptococcus is 
found, the condition is more acute, is attended with more con- 
stitutional symptoms, and demands prompt and energetic treat- 
ment. 

Treatment. — -The treatment of tuberculous rhinitis should be 
largely constitutional, the local treatment being purely palliative 
and cleansing. For this purpose there should be used, by means 
of an atomizer or Bermingham douche, the following : 

ly. Sodii biboratis, 
Sodii bicarbonatis, 

Sodii chloratis, da gr. viij (.48) ; 

Aqua? (tepid.), fl^j (30.). 

This solution should be used two or three times daily for effect, 
the object being to keep the membrane thoroughly clean. Should 
the secretion be very tenacious, the use of this douche should be 
followed by 

3^. Aquae cinnamomi, 
Hydrogeni peroxidi, 
Extract! hamamelidis (aqueous), da fl^j (30.). 

in the same manner as above. After thorough cleansing there 
should be applied to the irritated membrane an oily solution 
composed of: 

3$s. Camphorse, gr. j (.06) ; 

Menthol, gr. iij (.18) ; 

Acidi carbolici, gtt. ij (.12) ; 

Alboleni (liquid) flgj (30.). 

Constitutional treatment should consist in outdoor exercise. 
A diet containing plenty of fats, beef, and nitrogenous foods 
should be prescribed, and tonics administered. As to the form of 
tonics to be employed, it remains for the physician to choose that 
one best adapted to the individual case. The best results will be 
obtained, however, in the majority of cases by the administration 
of the lactate or peptomanganate of iron ; an equally good tonic 
alterative is the double sulphid of arsenic in doses varying from 
■jj to -| grain, according to the age of the patient. 

Caseous Rhinitis. — Synonyms. — Coryza caseosa ; Choles- 
teatomatous rhinitis ; Rhinitis caseosa. 

This rare disease seems to be more the result of some asso- 



EPIDEMIC INFLUENZA. 87 

ciated condition than a process actually involving the nasal mucosa. 
In the few cases reported, each shows different etiological fac- 
tors. There is an accumulation in the nasal fossa of a cheesy, 
gelatinous material, often to the extent of actual displacement 
of structures and facial deformity. There is associated with it 
an extremely fetid odor, fouler, if possible, than that occurring 
in ozena. No special micro-organisms are found except those of 
decomposition. Microscopically, the material shows fatty cells, 
granular leukocytes, stearin, and cholesterin crystals. The con- 
dition occurs in individuals with tubercular tendency, or in those 
who possibly have been infected with syphilis. In one case 
reported, the cause was believed to have been a myxomatous 
growth which had undergone degeneration. Caseous rhinitis was 
first described by Duplay and Follin in 1874. 

Treatment. — The treatment consists in removal of the septic 
material by curetment and the use of a solvent, such as bicarbon- 
ate and biborate of soda, 10 to 15 grains to the ounce, followed 
by an antiseptic irrigation, as hydrogen peroxid and cinnamon- 
water in equal parts. 

EPIDEMIC INFLUENZA. 

Synonym. — La grippe. 

Coryza is a prominent symptom, as a rule accompanied by 
painful and paroxysmal cough, but the constitutional symptoms 
accompanying it follow so rapidly as to allow of no mistake as 
to diagnosis. The involvement of the mucous membrane of 
the upper respiratory tract and of the accessory cavities, and 
the after-effects of this disease on these structures, are of grave 
import. 

Granting that the identity of Pfeiffer's bacillus has been suf- 
ficiently established to warrant its classification as the true etio- 
logical factor, it has a curious way of affecting and penetrating 
certain tissues, cavities, and locations of the mucous membranes 
which is peculiar to itself. I have seen following an attack of 
la grippe, or associated with it in most rapid succession, an 
involvement of the middle ear, this involvement being of an 
infectious nature and rapidly going on to suppuration. I have 
seen both middle ears involved, with associated involvement of 
both mastoids, the involvement being rapid and virulently infec- 
tious. 

As to the involvement of the frontal sinus, my own experience 
has been that such involvement takes place early in the disease 
and reaches the highest degree of its involvement during the 
height of the disease ; while the ethmoid cells are involved early 
or during the attack, and the inflammation frequently continues as 
a suppurative ethmoiditis. It is true that in an ordinary coryza 



88 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

there is usually some ethmoiditis, and that previous to, during, 
and following the infectious fevers the ethmoid cells are often 
involved ; but a peculiarity of ethmoiditis following grippe is its 
persistency and the virulent infectious conditions. The suppura- 
tive process seems unabating, and the rapidity with which pus is 
formed is something alarming. I think that in many cases necro- 
sis of the ethmoid cells occurs. Of the accessory cavities, the 
antrum is most frequently involved, and when involved rapidly 
goes on to suppuration. 

Tonsillar and peritonsillar involvement is quite common, the 
inflammatory process usually ending as a suppurative process with 
tonsillar or peritonsillar abscess. In some cases the peculiarity 
of the tonsillar or peritonsillar abscess is that for several days 
during the attack and afterward there is that peculiar raspy 
throat, sensitive, yet not markedly swollen, with localized spots 
of apparent infection. Even after the general symptoms have 
abated, suddenly there will light up a suppurative inflammatory 
process. The glandular involvement in a case following the 
grippe seems to be much more marked than in the ordinary sup- 
purating tonsil. 

As to the mucous membranes themselves, the phenomena are 
irregular, and in many cases curious. A mild attack may leave 
the mucous membrane irritated, aggravated, and thickened, and 
this thickening and aggravation continue apparently unrelieved by 
local treatment. Again, frequently during the attack the pain 
and discomfort to the patient are all out of proportion to the 
naked-eye appearance of the membrane. I have seen a number 
of cases which presented a very curious phenomenon which I have 
never observed associated with any other condition. It is this: 
While the membrane of the pharynx, nasopharynx, and nares is 
extremely sensitive, dry, painful, and uncomfortable, there is very 
little swelling, and in the course of a few hours blood-clots will 
form on the surface of the membrane, and yet there is no distinct 
hemorrhage. These can be removed and no bleeding will occur, 
and in the course of two or three hours the clot will re-form. It 
seems to be a capillary oozing on the surface of the mucous mem- 
brane. I have observed this phenomenon in the nose, nasophar- 
ynx, and pharynx. The common site is in the pharynx and naso- 
pharynx. Whenever blood shows in the expectoration it is 
always alarming to the patient. This apprehension, combined 
with the depression which is associated with and follows the 
grippe, has anything but a pleasing effect on the patient. It is 
especially alarming when the laryngeal structures are involved 
and this bloody exudate takes place within the larynx ; the patient 
is then positive that it comes from his lungs. A laryngeal exam- 
ination will clear up the diagnosis. 

Quite often we find, after an attack of influenza, although the 



EPIDEMIC INFLUENZA. 89 

patient made a good recovery, that he complains of a thickening 
of his mucous membrane. His own impression is that it " feels 
thick/' and on examination that is exactly what you find. It 
is not an edematous swelling, but it seems tough and infiltrated 
and lacks the luster and life of a normal mucous membrane. 
From examination of microscopical sections of this tissue I be- 
lieve that during the inflammatory attack there exudes into the 
perivascular tissue a peculiar albuminous material not unlike that 
which occurs in amyloid disease, and that this material, which is 
manufactured in the blood owing to some chemical change brought 
about by the toxins of the bacteria, is deposited in the tissue as 
an infiltrate. Treatment would bear out this fact, as in the 
majority of cases alteratives are productive of the best results. 

A curious fact about local treatment is that such solutions as 
nitrate of silver, iodin, chlorid of zinc, sulphocarbolate of zinc, 
etc., aggravate and make worse the inflamed area, while sedative 
oily solutions seem to relieve ; yet where there are local spots of 
ulceration it is absolutely necessary to use a germicidal solution. 
I prefer to use Loftier' s solution. I believe, in the cases where 
there is ulceration, that the absorption of the toxins or virus from 
the nidus of the infection is due largely to systemic phenomena 
of a marked depression and the cardiac and renal lesions. The 
systemic after-effects of the grippe are very much like the sys- 
temic after-effects of diphtheria and scarlet fever. 

As we know, frequently grave lesions follow an attack of the 
grippe or some latent lesion is aggravated by the attack. This I 
believe to be- explained on the same basis as diphtheria, scarlet 
fever, and the other infectious diseases ; it is the systemic effect of 
absorbed toxins. Should, however, there be no pre-existing lesion 
of the mucous membrane, local or of any internal organ, this after- 
effect is not likely to be so serious. 

As to the effect on tissue and function : The mucous mem- 
brane consists of a basement of membrane, upon which are 
epithelial cells, and under which are blood-vessels, glands, and 
nerves, the essential function of which is to secrete mucus. Any 
inflammatory lesion first alters the submucosa, which alteration 
depends upon the variety and severity of the inflammation. I 
will not attempt to discuss the part taken by bacteria in the pro- 
duction of the disease, as from my own experiments I find no 
germ which is constantly present. In those cases without pre- 
existing lesions the transudate from the vessel is undoubtedly more 
than a mere inflammatory exudate. I believe that there is a 
marked alteration in the liquid constituents of the blood, and that 
the exudate from the vessels is highly coagulable albuminoid 
material which infiltrates the tissue ; this infiltration, being more 
solid than fluid, by its pressure obstructs secretion, causing inter- 
ference with the function as well as with the nutrition of the parts. 



90 DISEASES OF THE ANTERIOR NASAL CA VITIES. 

In those cases in which there were pre-existing lesions I 
believe the exudate to be of the same character, but its effect on 
tissue and function I believe to be inconstant, being controlled 
largely by the pre-existing pathological alteration. 

LITHEMIC RHINITIS. 

The nasal symptoms are merely local manifestations of a sys- 
temic condition. The individual, without any exposure whatever, 
probably sitting comfortably at home, is suddenly seized with con- 
gestion of the nostril, with a tickling sensation in the nose, and 
frequent sneezing, followed rapidly by a thin, watery discharge 
from the nasal mucous membrane ; free lacrimation, burning, and 
itching in the nasal cavities, eyes, and nasopharynx. Not infre- 
quently is there associated slight asthmatic tendency. The 
secretion is decidedly irritating and frequently produces excoria- 
tion on the skin surface about the nostril. There must be 
something in the nasal secretion, which secretion coming in con- 
tact with the air, there is liberated in the chemical change an irri- 
tating material which acts on the peripheral terminal nerve fila- 
ments and the vasomotor system, causing the sudden congestion. 
The attack is quite similar to the effect produced by inhaling 
ammonia fumes. The so-called lithemic condition, or suppressed 
gout in some form, is the underlying cause. Owing to some 
chemical change in the secretion of the individual there is accumu- 
lated in the system a material which in the point of accumulation 
reaches that period in which it overflows, and the secreting glands 
liberate on the surface this material, either irritating in itself or 
when exposed to the air, and undergoes a chemical change, pro- 
ducing the irritant. 

From laboratory examinations I have frequently found an 
excess of ammonia salts and not infrequently the sulphocyanids. 

Treatment. — Local treatment in this condition is of prac- 
tically no curative value. A careful analysis of the secretions 
should be made, and the treatment based entirely on the result of 
this analysis. As the chemical analysis will vary in individual 
cases, it is impossible to outline a general treatment. Should the 
chemical analysis show excess of ammonia with cyanids, the 
therapeutic agent indicated will be entirely different than if 
ammonia were present without the cyanids. However, in general, 
the first step in the constitutional treatment should be to increase 
elimination, especially through the intestinal tract. Should the 
chemical analysis show the presence of any biliary products, the 
drugs should be administered to increase the action of the liver. 
The milk of magnesia, citrate of potash, benzoate of soda, bicar- 
bonate of potash, and phosphate of soda are indicated in certain 
chemical reactions, but the constitutional treatment should be, as 
stated before, entirely based on the result of the chemical findings. 



ACUTE RHINITIS IN THE YOUNG. 



91 



Acute Rhinitis in the Young. 1 

This condition differs but little from that observed in adults, 
save in such modifications as may arise from the relatively smaller 
nasal spaces and orifices of the connected structures. The causa- 
tive influences with certain limitations and the pathological char- 
acteristics are identical. The symptoms are practically the same 
— sneezing, evidences of discomfort, swelling of the nasal mem- 
brane, noisy mouth-breathing (especially during sleep), an abun- 
dant discharge from the nostrils, with some lacrimation or photo- 
phobia. In the very young an important symptom is the lessened 
ability of the infant to nurse, it being unable to grasp the nipple 
properly or exert sufficient suction. The attack, as a rule, runs 
a course of from one to two weeks, and the diagnosis of the con- 
dition is not difficult ; a differential diagnosis must, however, be 
carefully made between a simple acute rhinitis and that associated 
with congenital syphilis. The following table presents the chief 
points of importance in the early condition : 

Differential Diagnosis. — 



Specific Rhinitis. 

Parental history specific. 

Child small, imperfectly developed, 
shrivelled and senile in appearance. 

Skin unhealthy, and sallow in hue ; 
varied rashes present. 

Specific lesions present, including 
condylomata, mucous patches, copper- 
colored blotches, onychia, osseous en- 
largements, alopecia, or a peculiar lus- 
terless, brittle hair, ulcerated lips, rhag- 
ades, and, rarely, subcutaneous hemor- 
rhages. 

Enlarged liver and spleen. 

Child rarely smiles, has a plaintive, 
feeble voice, and a peculiar character- 
istic cry. 

Fretful and wakeful at night. 

Nutrition greatly impaired during 
local manifestations. 

Painless enlargement of glands, es- 
pecially cervical, cervicomaxillary, in- 
guinal and axillary. 

Runs a fixed course. 

Pyrexia absent. 

Tendency to ulceration of membrane 
and cartilage, with flattening of nose. 

Discharge purulent, with shreds of 
necrotic tissue, frequently blood- 
streaked and offensive. 

Formation of nasal crusts. 

Fissures and ulcers in al?e nasi. 



Simple Acute Rhinitis. 

Parental history non-specific. 
Child normal. 

Skin normal ; no characteristic rash. 

Absent. 



Normal. 

Child normal in these particulars. 



May fret occasionally, but, as a rule, 
sleeps fairly well. 

Nutrition unimpaired. 

Maxillary glands may enlarge ; not 
usually. Painful. 

Not definite ; irregular. 

Moderate fever at onset. 

No ulceration nor flattening, and 
rapidly terminates. 

Discharge never absolutely purulent, 
rarely blood-streaked, and is inoffen- 
sive. 

No such formations. 

Not seen. 



1 For Purulent Rhinitis in Children, see page 139. 



92 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

Simple acute rhinitis in children must not be confused with the 
purulent variety contracted by exposure to infection in the birth- 
canal of the mother. 

Prognosis. — The prognosis of acute rhinitis in infants is 
favorable if prompt treatment is instituted, but the condition is 
likely to become purulent and fetid if neglected, and if permanent 
alteration of the nasal mucous membrane occur. 

In the very young, acute rhinitis without some mechanical 
cause is a rare condition. In my own experience, in the majority 
of cases occurring in infants from a few weeks to six months of 
age, the acute rhinitis could usually be traced to some carelessness 
in bathing. For example, when the new-born child is first bathed, 
the nurse may carelessly allow the soap and water to come in con- 
tact with the nasal mucous membrane. This membrane, sensitive 
in adult life, is extremely so in the new-born. The irritation set 
up will produce in the infant symptoms identical with acute rhi- 
nitis. Indeed, the condition may be aggravated to one of almost 
purulent rhinitis owing to the fact that the patient is not able to 
keep the nostril clear. The mother and nurse should be instructed 
to avoid this danger. Also, attacks of acute rhinitis in children 
may be excited by irritating vapors or gases. As the little one is 
not capable of expression or locomotion, but is strictly passive, it 
may be placed in the direct line of dry air from the heaters, or 
noxious gases from the stove or the range, which may be the ex- 
citing causes of acute attacks. When an acute catarrhal condi- 
tion is once established in the infant, it should be given prompt 
attention. As the little one is not capable of keeping the nostril 
clear, the collected secretion will act as an irritant, saprophytic 
bacteria may gain ingress, the condition from being a simple one 
may become one of alarming gravity, and permanent changes may 
take place in the nasal mucous membrane. 

Treatment. — The treatment is necessarily purely local. The 
nostril should be cleansed with tepid milk, to which has been 
added 3 grains of sodium chlorid to the ounce. This should 
be followed by a tepid boric-acid solution of the same strength, 
and the nostrils cleared as thoroughly as possible. This cleansing 
process can be done by saturating cotton with the solution, then 
allowing it to drip into the nostril, working the end of the loose 
cotton into the nose as far as possible, thus preventing irritation 
of the sensitive membrane. The nose may then be taken between 
the thumb and index finger, and by drawing down — pressure and 
slight suction being thus obtained — and repeating the process sev- 
eral times, the nostrils can be thoroughly cleansed. There then 
should be dropped into the nostril 2 or 3 drops of liquid albolene 
or cosmoline. The treatment in such conditions should really be 
a preventive one, as a majority of cases in infants, outside of those 



VACCINE THERAPY IN DISEASES OF THE NOSE. 93 

associated with the diseases of childhood, are largely mechanical 
in origin. 

The complications are rare, but may be the same as in 
adults. 



VACCINE THERAPY IN DISEASES OF THE NOSE AND ACCES- 
SORY SINUSES. 

The subject of Vaccine Therapy offers unlimited possibilities 
for the future, and is one which merits a more thorough investiga- 
tion and extensive experimentation, as at the present time the 
results obtained by various investigators are so diverse and their 
opinions so conflicting that a definite estimate of the true value of 
this method of treatment is quite impossible. From the author's 
experience we may conclude that gradually we will determine in 
what particular cases this form of treatment will be beneficial. 

The limitations of vaccine therapy, as set forth by Sir A. E. 
Wright, are as follows : 

1. Vaccine therapy can be applied only where an exact and 
complete bacteriological diagnosis has been made, and where the 
diagnosis is kept up to date. 

2. Vaccine therapy can be applied only by those who have 
some acquaintance with bacteriology, some understanding of the 
rationale of vaccine therapy, and a knowledge of the dose of the 
particular vaccine which it is proposed to employ. 

3. A limit is placed to the efficacy of inoculations by the 
fact that there are definite limits to the responsive power of the 
patient. 

4. Successful results can be obtained only where an efficient 
lymph stream can be conducted through the foci of infection. 

5. In long-standing infections vaccine therapy can give defi- 
nite results only after a long succession of inoculations, and there 
is no security against a relapse until the infection has been com- 
pletely extinguished. 

6. In a not inconsiderable percentage of cases it is essential to 
success that the dose of vaccine shall be controlled by measure- 
ments of the opsonic index. 

The theories upon which opsonic treatment is based are out-, 
lined by Joseph C. Beck, as follows : 

Bacteria affecting the body are attacked by leukocytes which 
ingest them. 

The number of bacteria which can be ingested is of varying 
quantity. 

The number of bacteria which can be ingested depends upon 
their preparation by substances present in the plasma of the blood, 
known as opsonins. 



94 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

The exact nature of opsonins is not known, but it is known 
that they are not identical with the agglutinins, antitoxins, etc., 
which are also found in the plasma. Their action is not on the 
leukocytes, but on the bacteria which they prepare for inges- 
tion. 

Opsonins are present in normal blood as well as in the blood of 
infected individuals. The opsonic strength of normal blood is 
practically constant, but varies slightly with the individual and 
general health, nutrition, etc. The opsonic strength of an infected 
individual is lower than that of a normal individual, and the rela- 
tion between the number of bacteria ingested by the leukocytes of 
the infected person to the number of bacteria ingested by the leuko- 
cytes of a healthy individual gives us a value which we call the 
" opsonic index." 

For instance, if ten bacteria are ingested on the average by the 
leukocytes of a healthy person and five of the same bacteria by 
the leukocytes from an infected person, the opsonic index of the 
latter would be 0.5. 

The opsonic index of an infected person may be increased by 
injecting into him killed cultures of his infecting organism. 

For instance, if an infection is due to the Staphylococcus albus, 
some of these particular germs are taken, grown on suitable cul- 
ture-media, and when sufficient quantity has been obtained, the 
culture is washed off with .85 per cent, sodium chlorid solution, 
to which a little carbolic acid has been added. The mixture, well 
shaken, is standardized to contain 300,000,000 cocci to the cubic 
centimeter, which represents one hypodermic dose. 

It is important to inject cultures made from the particular in- 
fecting organisms, because it is known that even such well-known 
organisms as the Staphyloccoccus albus are subject to great varia- 
tions in virulence. 

Skillern thinks the value of this method in sinus disease is 
questionable for the following reasons : Acute inflammations exhibit 
a marked tendency toward spontaneous recovery, and if proper 
treatment is instituted a cure will almost certainly result. The 
majority of chronic cases are associated with mixed infection; 
therefore, when the culture is plated, how can one decide which 
particular organism is causing the suppuration ? To make a vaccine 
of the mixed culture is unscientific and will lead to no satisfactory 
result. It will be seen then that treatment along these lines is 
largely a matter of conjecture. 

The indications for this treatment, according to Skillern, are 
not many, but still there are cases in which it should be tried. (1) 
In a case of chronic sinusitis that resists the ordinary treatment 
and in which a pure culture of the infecting micro-organism is 
obtained. (2) In old chronic frontal sinusitis which did not im- 



VACCINE THERAPY IN DISEASES OF THE NOSE. 95 

prove under intransal treatment, yet was not of sufficient severity 
to warrant an external operation. (3) In cases of chronic eth- 
moidal suppuration which did not entirely heal after a more or 
less complete exenteration. In the latter class Skillern has ob- 
tained success after all local means have failed. 

R. W. Allen says : " In infections of the antrum and acces- 
sory spaces we are confronted by no little difficulty in arriving 
at a just appreciation of the scope and value of vaccine treat- 
ment. As to the frequency with which involvement of one or 
more of the accessory sinuses occurs during attacks of acute 
rhinitis statistics are wholly lacking. Personally, I think that 
it does occur in at least 80 per cent, of all cases, and that it is 
especially frequent in acute catarrhs due to the B. influenzae, M. 
catarrhalis, and pneumococcus. If this be so spontaneous cure 
must be very frequent. The rapidity with which an antrum full 
of pus can clear up is very striking. I have observed a complete 
shadow, as seen by transillumination, entirely disappear within 
thirty-six hours and not recur. The ease with which this can 
happen must obviously depend largely upon the position of the 
opening with regard to the floor of the cavity. If this be near the 
floor, evacuation is easy ; the higher up it is, the greater the ob- 
struction to natural drainage. The poorness of the blood-supply 
and the scanty amount of tissue covering the bony walls make it 
difficult to understand how the copious exudate is formed and the 
mechanism whereby absorption occurs of the residue which fails to 
drain away. The fact remains that several drams of pus may be 
secreted daily, and that spontaneous evacuation and absorption 
may occur with extreme rapidity. 

" It is, therefore, with considerable hesitation, that an expensive 
course of vaccine treatment should be suggested to any case of 
acute infection of the antrum until opportunity for spontaneous 
cure has been afforded and aided by attention to the intranasal 
abnormalities, the institution of facilities for proper drainage, and 
the application of lavage and other usual remedial measures. 

" Here I would like to say that if artificial drainage has to be 
established, and the possibility of future vaccine treatment has to 
be considered, then an intranasal operation will be better procedure 
than puncture through a tooth-socket, for this latter affords un- 
limited opportunity for the continual ingress of contaminating 
organisms from the mouth, organisms which may prove especially 
refractory to vaccine treatment. As soon, however, as an acute 
infection shows a tendency to assume a chronic state resort should 
be made to vaccine therapy for the following reasons: (1) Exten- 
sion to neighboring cavities may be obviated ; (2) truly chronic 
infections prove decidedly refractory to specific treatment. In 
by far the greater proportion of the 30 cases which I have seen 



96 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

during the past three years, operative measures have been taken and 
lavage persisted in for several years. In none of these have I 
succeeded, even after two years treatment, in producing such com- 
plete cure that vaccine treatment could be altogether discon- 
tinued. What I have achieved has been as follows : (1) Great 
diminution of the secretion, perhaps to such a degree that the per- 
formance of lavage once every two or three days by the patient 
himself has sufficed to maintain a practically complete absence of 
pus formation ; (2) total disappearance of exacerbations and of re- 
current attacks of acute nasal catarrh ; (3) considerable improve- 
ment in the general health. The best results I have obtained have 
been in two very chronic cases, one of infection by the bacillus of 
Friedlander, the other by the B. coli. In each of these operative 
interference was refused, and could not be insisted on, yet the final 
result was almost complete cure ; a short course of vaccine treat- 
ment, has, however, had to be continued at four- to six-monthly 
intervals. 

" If any measure of success is to be achieved in these very 
chronic cases it must be remembered (1) that very high ultimate 
dosages, indeed, may be requisite, such as 2,000,000,000 or even 
5,000,000,000 B. influenza?, 1,000,000,000-2,000,000,000 B. of 
Friedlander, B. coli, or B. proteus, 2,000,000,000-4,000,000,000 
staphylococcus. The blood supply, especially to the antrum, 
frontal, and sphenoidal sinuses is small, hence the amount of 
immune bodies there is small in any given blood volume ; as there 
is difficulty in increasing the latter it is necessary greatly to aug- 
ment the former. 

" (2) That treatment may have to be prolonged, and should be 
re-continued after intervals, say, of every six months. 

" (3) That in cases of multiple sinusitis the bacterial flora of the 
several cavities may differ, and that great care is requisite in 
making a correct bacteriological diagnosis and in checking the 
progress of the immunization. 

" (4) That re-infection or fresh infection by other bacteria may 
at any time occur ; inasmuch as the most likely new invaders are 
the other catarrhal organisms, a wise procedure is to anticipate the 
possibility, as far as possible, by the administration, at six- 
monthly intervals, of three progressive doses of the combined vac- 
cine for colds of the Wimpole Institute. 

" (5) That when large dosages are being employed the intervals 
must not be unduly short ; ten days or slightly longer usually 
proves a satisfactory one. 

" (6) That if progress is interrupted fresh infection is a most 
likely cause, and is to be determined by careful re-investigation of 
the bacterial flora." 



MEMBRANOUS RHINITIS. 97 



MEMBRANOUS RHINITIS. 



Under this heading is included (1) croupous or pseudomem- 
branous rhinitis ; (2) fibrinoplastic rhinitis ; (3) diphtheritic rhi- 
nitis — the form due to the action of the Klebs-Loffler bacillus. 

Croupous or Pseudomembranous Ehixitis. 

Synonyms. — Membranous rhinitis ; Primary pseudomem- 
branous rhinitis. 

Definition. — Croupous rhinitis is an acute inflammation of 
the nasal mucous membrane, occurring in both children and adults, 
though running a longer course and with severer symptoms in the 
former. It is characterized by the deposit of an albuminous exu- 
date, forming a false membrane, which lies upon the epithelial 
coating and does not involve the deeper structures. This exudate 
does not tend to organize. 

Etiology. — Croupous rhinitis is due, at least in a majority of 
cases, to local irritation produced by the action of micro-organisms 
on the surface of the mucous membrane, associated with lessened 
cell-resistance ; or it is due to some constitutional condition in 
which the individual cell-resistance is less than normal. It is not 
produced in each case by the same specific bacteritic cause, but there 
may be a number of micro-organisms associated as causal agents. 
The Streptococcus pyogenes is often, unquestionably, the chief ex- 
citing factor. This may or may not be associated with the vari- 
ous forms of the staphylococci and the attenuated form of the 
diphtheria bacillus known as Von Hoffman's bacillus. Cases have 
been observed following nasal operations involving the use of the 
galvanocautery, section of the mucous membrane, or the insufflation 
of impure water after operations. In one case observed by the 
author the application of the cautery had been followed by the 
formation of a croupous membrane, and the process, extending up 
through the nasal duct, had involved the anterior conjunctival and 
palpebral surfaces with a similar structure having no tendency to 
organization. It has been reported as following measles and ton- 
sillitis, as occurring with a history of hereditary syphilis, and, in 
one case, as subsequent to a toxemia originating in a razor-cut. 
The disease is more prevalent in America than in Europe, and its 
predisposing causes are largely the same as those of diphtheria, 
bad hygiene and defective sanitation being causal agents in low- 
ering the individual resistance. 

Pathology. — The pathology of croupous rhinitis is at first 
essentially that of an acute catarrhal rhinitis. The nasal mu- 
cosa is swollen, turgid, and congested ; there follows an abun- 
dant escape of serum and cellular elements upon the surface, and 
7 



98 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

the discharge becomes somewhat purulent, rarely fetid, and causes 
excoriation of the upper lip. In a fully-developed case there will 
be found the croupous membrane, varying in extent from a small 
patch to involvement of the nasal passage ; in adults thin, gelat- 
inous, but tenacious and of a somewhat pearly tinge. In chil- 
dren the exudate may be thicker and even somewhat friable in 
texture. This membrane, placed upon the surface of the mucosa, 
does not involve its deeper structures, and never goes on to com- 
plete organization. 

Microscopically, the membrane presents the characteristic ap- 
pearances of a croupous exudate — a network of fibrin-threads 
entangling leukocytes, some few red blood-cells, desquamated 
epithelium in various stages of disintegration, and various 
bacteria. 

The usual site of the process is the surface of the lower and 
middle turbinates and the anterior part of the septum ; it may 
occupy the entire area of the nasal mucosa. It has a marked 
tendency to recurrence upon removal. 

Symptoms. — The attack begins — as does the ordinary sim- 
ple acute rhinitis — with chilliness, or even a decided chill, malaise, 
headache, pain in the back and limbs, fever to 101° or 103° F., 
and anorexia. Swelling of the nasal membrane succeeds, occlu- 
sion of the passage follows, with mouth-breathing and, perhaps, 
sneezing. The dry stage of the inflammation is very brief, and 
there soon follows an abundant discharge, at first clear, but soon 
becoming thicker, more opaque, but rarely fetid. The fever drops 
to 101°, or 100° F., the sense of malaise remaining marked. 
There are frontal headache, partial or complete loss of smell, and 
neuralgia of the nasal nerve may become an annoying feature. 
With the thickening of the nasal discharge there begin to be 
formed shreds or small pieces of the false membrane, and this 
usually constitutes the first distinctive feature of the symptoms. 
On inspection the membrane will be seen, unless the occlusion 
of the nasal chamber by the engorgement of the turbinal mucosa 
be so complete as to prevent a view. The condition lasts, as a 
rule, in adults from eight to fourteen days, and in children from 
ten days to five weeks. 

Diagnosis. — The diagnosis of this membranous inflammation 
from simple acute rhinitis is based upon the presence of the 
shredded bits of membrane in the nasal discharge, and on the 
presence of the membrane as revealed by inspection. The differ- 
ential diagnosis from nasal diphtheria, however, must be carefully 
made, and the following table will be found of use : 



MEMBRANOUS RHINITIS. 99 

Differential Diagnosis.-— 

CROUPOUS RHINITIS. NASAL DIPHTHERIA. 

Constitutional symptoms present, but Constitutional symptoms marked and 

not severe. usually severe. 

Sporadic. Epidemic ; sporadic cases may occur. 

Primary, and usually the membrane Usually secondary, either from auto- 

is confined to nasal space. infection or extension, with false mem- 

brane on fauces, pharynx, or soft palate, 
either accompanying or preceding. 

No albuminuria. Albuminuria. 

Xo lymphatic involvement. Cervical glands enlarged. 

Color of membrane brighter and Color grayish or dirty white ; shaggy, 

pearly in tint. 

Membrane superficial. Involves deeper layer of mucous 

membrane. 

Membrane is readily detached. Closely adherent. 

Seldom leaves a bleeding surface on Always bleeds, 

removal, except perhaps a slight capil- 
lary oozing. 

Xo ulcer nor scar follows removal. May ulcerate and leave subsequent 

scar. 

Discharge slightly, or not at all, fetid. Discharge fetid. 

May become chronic. May become chronic. 

May occur at any age. Most common in the young. 

No paralysis. May be paralysis of soft palate. 

Prognosis. — The prognosis for the attack is extremely favor- 
able, especially under proper treatment. The predisposing in- 
fluence of one attack upon subsequent attacks must, however, be 
carefully borne in mind. 

Treatment. — In all membranous cases, either nasal or phar- 
yngeal, the patient should be isolated until the diagnosis is 
clearly established. 

Local Treatment. — For the purpose of removing the mem- 
brane there should be used a warm alkaline douche consist- 
ing of biborate of soda and bicarbonate of soda, of each 8 
grains to the ounce of water. This will clear away the loose 
material, and should then be followed by hydrogen peroxid 
(15 volume) diluted with an equal amount of cinnamon water, 
applied either by means of spray, douche, or cotton pledget. This 
application will coagulate the albuminous material left after the 
first cleansing. The alkaline solution should now be repeated, 
and any particles of the caseous material still adherent should be 
removed by means of cotton loosely wrapped on a probe, care 
being taken not to injure the exposed and inflamed membrane. 
The surface should then be carefully dried, and there should be 
applied to the site of the membrane, by means of a cotton carrier, 
Lofller's solution, which is : 

]fy. Toluol, 36 parts ; 

Alcoholis absoluti, 60 " 

Liquoris ferri sesquichloridi, 4 " 



100 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

This application should not be made more than three times daily, 
although the cleansing solution may be used as often as once every 
two hours. For the relief of the irritation and the feeling of raw- 
ness left after the removal of the membrane, if the Loffler's solu- 
tion is not used, the following oily preparation may be employed : 

3^. Olei eucalypti, gtt. ij (.12) ; 

Acidi carbolici, gtt. j (.06) ; 

Olei cassiae, gtt. iv (.24) ; 

Alboleni (liquid), flgj (30.).— M. 

Internal Treatment. — As the progress of the disease is largely 
controlled by the general condition of the patient, the constitutional 
treatment should be directed toward the improvement of the general 
cell-resistance. First, there should be thorough cleansing of the 
intestinal tract. For this purpose, and also for its general alter- 
ative effect, there should be administered calomel in y^-grain 
doses, with 1 grain of bicarbonate of soda every hour for ten 
doses. This should be followed in three hours by citrate of mag- 
nesia. This course of medication should be repeated on the second 
day, as the repetition materially shortens the attack and lessens its 
severity. As a tonic, there should be administered iron, quinin, 
and strychnin. More rapid results can be obtained by the use of 
the tincture of the chlorid of iron, which can be given alone in 
from 10- to 20-drop doses. There should be administered also 
bromid of quinin in from 2 to 5 grains, with extract of mix 
vomica -J- grain every four hours, in either pill or capsule, the 
dosage controlled by the age of the patient. If the fever be of 
such severity as to demand special attention, the usual antipyretic 
measures should be employed. 

FlBRIXOPLASTIC KhINITIS. 

Fibrin oplastic exudates are much the same as those occurring 
in the croupous variety mentioned before, except that they are 
more highly fibrinous and are of a higher grade, tending to organi- 
zation. No special bacteria seem to be associated with them, 
nor is the individual's general health necessarily impaired. Bad 
hygienic condition and bad sanitation seem to predispose to the 
affection. It is most common in the young. 

The fibrinoplastic variety of rhinitis begins as any other inflam- 
mation that is catarrhal, followed rapidly by a highly-fibrinous, 
coagulable, albuminoid exudate, which forms on the surface. 
Capillary budding may take place in localized areas, and vascular- 
ization follow. In two cases seen at the St. Agnes Hospital, an 
examination of the nose showed the false membrane extending 
from the nasal mucocutaneous surface to the nasopharyngeal mem- 




Fig. 41. 



-Laminated fibrinoplastic exudate, partially organized. The picture shows an 
oblique section of a blood-vessel with illy-formed wall. 



FIBBIXOPLASTIC BHIXITIS. 101 

brane, also involving the pharynx and tonsils. This membrane 
was distinctly laminated, appearing the same in both nostrils and 
completely obstructing nasal breathing. On attempting removal, 
it was found to be firmly adherent to underlying structures, and, 
when forcibly detached, there followed considerable hemorrhage, 
largely capillary oozing. The bleeding occurred on the surface of 
the mucous membrane, and there was no ulceration (Fig. 41). The 
membrane was so firmly adherent that it had to be removed with 
forceps, and could be detached only in small pieces. Serum-tube 
inoculations from the infected area showed no virulent germs 
present, except staphylococci. The membrane formed in the 
anterior nares showed much further organization than that found 
in the posterior part of the anterior nares. The membrane was 
sufficiently organized to permit of hardening and section-staining, 
which showed organized and unorganized material, fibrin entan- 
gling in its meshes leukocytes and epithelial cells. The fibrin was 
distinctly laminated, and the layers next to the mucous membrane 
showed greater organization than the central layer, with partial 
vascularization. While the organization was irregular and not 
complete, yet it demonstrated that, in order to even partially 
organize, capillary budding must have taken place. 

This variety of membranous inflammation occurs sporadically, 
and shows no infectious or contagious properties. It bears the 
same relation to the croupous variety that an aplastic exudate 
does to a plastic, the difference being simply one of degree. 

This variety of inflammation occurs in the chronic form. The 
symptoms and pathology differ very little, if any, from the acute 
variety. It is simply a continued fibrinous inflammation. 

Treatment. — Cleansing solutions alone will have little effect 
on the membrane, its removal being effected by the use of for- 
ceps. It will be found that the surface will bleed in irregular 
areas ; such surfaces should be touched with a 15 percent, chromic- 
acid solution, after the nostrils have been cleansed with hydrogen 
peroxid (15 volume) and a simple alkaline wash. The surface 
should be carefully watched, and any tendency to re-formation of 
the membrane should be arrested by the application of the chromic- 
acid solution. 

General Remarks. — Before passing to the next variety of 
membranous rhinitis, it may, perhaps, be best to remind the stu- 
dent that in certain cases, instead of a succeeding acute catarrhal 
inflammation, an intensification of the acute cause leads to an 
exudate of an altered character, more fibrinous, with subsequent 
formation of a superficial fibrinous membrane. This is seen in the 
membrane-formation following inhalations of chlorin, ammonia, 
etc., and in that sometimes following cauterization. The grade of 
this exudate is slightly higher than the croupous, yet not so high 
as the fibrinoplastic variety mentioned above. It is more like a 



102 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

coagulation-necrosis, differing from the diphtheritic in that it is 
not due to any special micro-organism nor accompanied by any 
characteristic constitutional symptoms. The local treatment is 
largely the same as has been given. 

Diphtheritic Ehinitis. 

Definition. — An acute inflammation of the nasal mucous 
membrane due to a specific germ, the Klebs-Loffler bacillus. It 
is characterized by severe constitutional symptoms from the ab- 
sorption of poisonous products engendered by the germ at the 
site of invasion, and by the formation locally of a characteristic 
false membrane. The disease is highly contagious, and one attack 
confers no immunity from subsequent infection. 

Synonym. — Nasal diphtheria. 

For discussion of the etiology, pathology, symptoms, prognosis, 
treatment, complications, and sequelae the reader is referred to the 
article on Diphtheria (page 530)^ The differentiation between 
diphtheritic rhinitis and croupous rhinitis may be fouud under the 
latter article (page 99). 

Chronic Form. — Occasionally there is observed a chronic 
form of rhinitis following diphtheria, in which from the nasal mu- 
cous membrane the bacillus of diphtheria can be isolated, while in 
the nasopharynx and pharynx all bacterial and clinical evidences 
have disappeared. This chronic form is usually unilateral, which 
points to the probability that there is some slight infection of one 
of the accessory sinuses, and it is from this source that the irrita- 
tion is kept up. There is a mucopurulent discharge from the nos- 
tril, slight tendency to bleeding, occasional shreddy membrane, but 
there is complete absence of constitutional symptoms. Unfortu- 
nately, as long as the bacillus of diphtheria is present it will ne- 
cessitate the isolation of the patient. In this chronic form careful 
examination should be made as to the probable involvement of the 
accessory cavities, and by the local use of antiseptics and the in- 
ternal administration of the antitoxin the condition can be relieved. 



0CCUPATI0N=RHINITIS. 

Definition. — An acute inflammation of the nasal mucous 
membrane, differing from simple rhinitis only as to cause. 

Synonym. — Traumatic rhinitis. 

Etiology. — This variety may be caused by irritating vapors, 
as those of chlorin, ammonia, iodin, bromin, or by irritating sub- 
stances suspended in the atmosphere, as observed in the case of 
millers, coal-miners, wood-carvers, brush- and hat-makers, weavers, 
and all persons engaged in kindred employments, and is in reality 
a condition analogous to pneumonokoniosis. Irritants, such as 



OCCUPA TION-RHINITIS. 1 03 

steam or smoke, should also be classed as causes, although the 
nasal mucous membrane has much more resisting power, and does 
not suffer in' the same degree as the pharynx from exposure to 
these agents. Direct injury and the presence of foreign bodies 
are important etiological factors. The condition brought about by 
the irritation of the pollen of plants will be considered under hay 
fever. The fumes from such drugs as bichromate of potassium, 
mercury, arsenious acid, and osmic acid are also classed as causes, 
and are exemplified in persons whose occupation necessitates their 
continued exposure to them. This should be carefully considered 
in complicated cases, and the occupation of the individual may 
lead to valuable aid in diagnosis and treatment. 

Pathology. — The pathological alterations in this variety of 
rhinitis do not differ from those found in the simple acute form, 
except when due to the irritating fumes of bichromate of potassium, 
mercury, and arsenious acid, the poisonous effect being purely local, 
and not the result of constitutional absorption, as is found in 
chronic phosphorus-poisoning. Following the phenomena of acute 
inflammation there are local areas of degeneration which ex- 
tend to, and involve, the submucosa and form ulcers, which, at 
first small and round, subsequently enlarge and become oval. This 
usually occurs on the cartilaginous septum, and may lead to per- 
foration. 

Symptoms. — The symptoms of traumatic rhinitis are a 
tickling sensation in the nose, followed by paroxysmal sneezing, 
associated with, or followed by, an abundant discharge, which at 
first is watery in character, but later, as the secretions accumulate 
on the membrane, the bacteria of decomposition (saprophytic) 
cause the discharge to become greenish in tinge and much more 
tenacious. These symptoms occur regardless of which substance 
is the cause. The symptoms being largely the result of local irri- 
tation, when superficial necrosis begins, the secretion forms in 
crusts ; and later, as ulceration takes place, hemorrhage occurs. 
There is rarely, if ever, any odor. The ulceration is usually on the 
upper and posterior part of the septum or turbinated bodies — more 
commonly on the septum — and may extend even to the discharge 
of portions of any of these structures. The lower and anterior 
portion of the cartilage remains intact, and there is never any 
falling-in of the nose. 

Prognosis. — With the removal of the cause the prognosis is 
usually good. If the irritation has not been kept up a sufficient 
length of time to produce permanent pathological changes in the 
mucous membrane, after the removal of the irritating cause the 
catarrhal condition gradually disappears and the condition has not 
predisposed the individual to catarrhal inflammation. 

Treatment. — Remove the cause. In individuals whose occu- 
pation necessitates exposure to the irritating substances, the nasal 



104 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

membrane should be protected by moistened cotton or woollen 
plugs. When ulceration takes place, the same treatment as in 
simple ulcer should be employed — cleansing, drying, and the appli- 
cation of liquid astringents, as 3 per cent, chlorid of zinc or 5 per 
cent, alumnol. Before ulceration, alkaline cleansing solutions 
should be used, such as — 

Ify. Acidi carbolici, 

Sodii biboratis, da 10 per cent. ; 
Glycerini, 30 per cent. ; 

Aquse destillatse, 50 per cent. 

This should be followed by — 

1^. Olei cassia?, 

Olei santali, da gtt. v (.3); 

Alboleni (liquid), flgj (30.). 

or compound tincture of benzoin with an equal part of boroglyc- 
erid, 50 per cent., for its sedative action. 

HYPERESTHETIC RHINITIS. 

Hyperesthetic rhinitis should be considered under nasal neu- 
roses. While the inflammatory condition present with its asso- 
ciated phenomena is, in a measure, a local condition, nevertheless, 
it is controlled by, and dependent upon, some peculiar susceptibil- 
ity on the part of the individual to irritating agents from without 
or manufactured within the body. Without this susceptibility on 
the part of the individual, this variety of rhinitis would not be 
separate and distinct, but could be classed either under simple acute 
rhinitis or occupation-rhinitis. 

For the complete article on this subject, reference should there- 
fore be made to the chapter on Neuroses (page 191). 

ULCERATIVE RHINITIS. 

Under this head, or that of its Latin equivalent, rhinitis 
ulcerosa, some writers describe various forms of ulcerative proc- 
esses of the nasal mucosa. There is, however, no inflammatory 
condition of the membrane in which ulceration is in such pre- 
dominance or of such constant type as to warrant the use of the 
term in a distinctive sense. Ulceration is, however, of far too 
common occurrence, existing as it does with greater or less fre- 
quency in every morbid nasal process, to receive but a passing 
notice in the descriptions of the various diseases. The author has 
therefore devoted a special chapter to the consideration of Ulcers 
(page 184), with reference especially to their pathology, special 
characteristics, and local treatment, to which the reader is referred. 



PHLEGMONOUS RHINITIS. 105 



EDEMATOUS RHINITIS (ACUTE). 

Acute edematous rhinitis is a separate and distinct condition 
from rhinitis edematosa or cyanotic rhinitis. 

The acute condition is identical, as regards pathological altera- 
tion, with the edema occurring in any other structure — more likely 
to occur here than elsewhere, however, because of the fact that the 
mucous membrane is not supported by muscular structure. 

The condition is brought about by sudden changes in the vas- 
cular tissue, from which, due to its overdistention, there is a 
watery infiltration of the connective-tissue spaces of the sub- 
mucosa, of the connective-tissue cells, and possibly of some of the 
epithelial cells of the surface. If the watery infiltration is con- 
tinued a sufficient length of time to interfere with the nutrition, 
the process will pass from edematous into hydropic degenera- 
tion. It differs from the infiltration that occurs in simple 
acute rhinitis or any simple inflammatory process only in this 
respect, that the cause is dependent upon some irritation to the 
mucous membrane, either direct or transmitted, which brings 
about a sudden and rapid distention of the vessels, with leak- 
age of liquor sanguinis, the inflammatory phenomena not pre- 
ceding, but rather following the leakage, similar to an injury in 
any lax structure, such as an ordinary black eye, in which the 
swelling or edema takes place suddenly and the phenomena of 
inflammation orderly follow. The condition would be seen, then, 
after inhalations of steam, highly irritating fumes, and following 
injuries not only to the membrane itself but also to the bony 
framework and connective tissue of the nose. 

Treatment. — The affected area should be punctured, if the 
severity of the nasal obstruction justify this procedure, as the 
majority of these acute edematous conditions will subside of 
themselves in twenty-four to forty-eight hours. However, if it 
is necessary to puncture the tissue, 6 per cent, sulphocarbolate of 
zinc or 3 per cent, chlorid-of-zinc solution should be applied as 
frequently as demanded by the existing condition. Should there 
be much irritation, drop into the nostril a few drops of plain 
benzoinol. Repeated applications of 8 per cent, solution of supra- 
renal extract is highly beneficial in some cases, while in others 
the reactionary congestion is quite marked. 

PHLEGMONOUS RHINITIS. 

Phlegmonous rhinitis is nothing more than acute abscess of the 
septum, or an abscess involving merely the submucosa of the 
mucous membrane. It differs very little from the ordinary nasal 
furuncle except in position and severity. The condition is not 
difficult of diagnosis, as it shows a distinct localized swelling on 



106 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

one or both sides of the septum, and has the appearance of, and is 
accompanied by, the same clinical phenomena as acute abscess for- 
mation elsewhere. If seen early, local application for the pre- 
vention of suppuration should be used. Paint the part with 
iodin, followed by applications of cold in the form of ice or 
cloths wrung out of ice water. If, however, it has gone to sup- 
puration, free incision should be made and heat applied. The 
condition may be associated with empyema of the antrum of 
Highmore or with alveolar abscess due to diseased teeth. 

Frequently a general septic condition may be produced by 
infection through the nasal cavity. This infection is not in all 
cases systemic ; it may be limited to the mucous membrane of the 
pharynx, soft palate, and buccal cavity and tongue. I have seen 
such irritation from infection of the nose and also produced by appli- 
cations of irritating drugs to the nasal mucous membrane. I have 
also seen the irritation of these structures in individuals who were 
addicted to the drug habit, especially by application of the drug 
to the nasal mucosa. 



CHAPTEE V. 

DISEASES OF THE ANTERIOR NASAL CAVITIES. 

Chronic Inflammatory Diseases. 
Chronic Khinitis. 

a. Simple Chronic Ehinitis. 

b. Intumescent Ehinitis. 

c. Hyperplastic Ehinitis. 

d. Ozena as a symptom. 

e. Atrophic Ehinitis. 
/. Purulent Ehinitis. 
g. Nasal Hydrorrhea. 

h. Edematous Ehinitis (Cyanotic). 

i. Specific Inflammations (Granulomata). 

1. Syphilis. 

a. Acquired. 

b. Congenital. 

2. Tuberculosis. 

3. Glanders. 

4. Leprosy. 

5. Actinomycosis. 

6. Ehinoscleroma. 

SIMPLE CHRONIC RHINITIS. 

Definition. — Simple chronic rhinitis is a chronic inflamma- 
tion of the nasal mucous membrane, occurring as the result of 
prolonged irritation or of successive attacks of the acute form. 
It is characterized by a relaxed and boggy condition of the mem- 
brane, alteration in the amount and character of the secretion, and 
an increased susceptibility to acute exacerbations. It is interme- 
diate between simple acute and beginning atrophic rhinitis. 

Synonyms. — Catarrhus longus ; Chronic blennorrhea ; Chronic 
coryza ; Chronic nasal catarrh ; Chronic rhinitis ; Chronic rhinor- 
rhea ; Fluxus nasalis ; Rhinitis chronica ; Rhinitis simplex ; Sim- 
ple chronic nasal catarrh. 

Etiology. — Simple chronic rhinitis is due either to repeated 
attacks of the acute form or to a continuation of a severe attack. 
The predisposing causes of this condition are identical with those 
of simple acute rhinitis — already given — and its exciting causes, 
either repeated or prolonged exposure to the exciting causes of the 
acute type. It is peculiarly liable to follow the simple form 
occurring in the infectious diseases, or the acute rhinitis of the 
new-born. The disease is most common between the ages of ten 
and thirty-five. 

107 



108 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

Pathology. — The membrane and erectile tissue are relaxed, 
flabby, readily distended by blood, and present all the characteris- 
tics of an atonic state of the vascular system. Through repeated 
or prolonged inflammatory distention the vessel-walls partially 
lose their normal contractibility (Figs. 42, 43). The venous plexuses 
of the turbinate bodies become enlarged through overdistention. 
There is a heightened permeability of the vessel-walls as the 
process advances, and an increased escape of the blood-elements, 
notably the white corpuscles, which penetrate the tissue, pro- 
liferate, and, together with the proliferation of the fixed connec- 
tive cells, give rise to new tissue of inflammatory origin. As the 
simple chronic inflammatory condition advances, and after the 
organization of the newly-formed tissue, but before contraction, 
there occurs the intermediate stage, which goes on to contraction 
and passes into the atrophic variety, as described on page 129. At 
this stage the symptoms are almost identical with hyperplastic 
rhinitis, and are identical with the early stage of the atrophic 
just as contraction begins. It is this intermediate stage that is so 
often called hypertrophic. There is a varying amount of surface- 
exudate, and migrated cells, with degenerated epithelium ; and the 
prolonged pressure due to the vascular distention and increase in 
connective tissue leads to a certain amount of glandular atrophy. 

Symptoms. — Usually the first symptoms to annoy the patient 
are the presence of an increased nasal and, sometimes, postnasal 
discharge, aggravated upon trivial exposure, and with a constant, 
ill-defined sense of nasal discomfort. Early in the establishment 
of the disease the secretion is thin and watery ; later, as a rule, 
it becomes thicker and more tenacious, mucopurulent, or even 
purulent. In some cases there form upon the surface dry green- 
ish crusts, or thin stringy bridges crossing the nasal spaces. These 
crusts may become infected with saprophytic bacteria and give 
rise to an annoying odor ; or in their removal the patient, through 
constant irritation by picking, may cause serious ulceration of the 
vestibule and septum, which may go on to perforation. Occasion- 
ally, if it should occur in the debilitated, the discharge may 
take the form of a profuse, non-irritating flow of clear, watery 
fluid. There is partial — or occasionally complete — intermittent 
stoppage of the nose, with a corresponding degree of mouth-breath- 
ing, and sometimes a tendency of gravitation is shown by the 
occlusion of the lower space on lying down. More or less stuffi- 
ness of the nose is present, a dull heavy pain over the nasal bridge, 
dull frontal headache, and in severe cases a mental hebetude and 
an indisposition for work. Various neuroses may occur — itching 
or tickling in the nose ; sneezing ; vomiting ; spasmodic cough, 
usually dry and barking ; or asthma. The voice is nasal in tone. 
The sense of smell, at first unimpaired, may later become obtunded. 
Constitutional debility may develop, due probably to digestive 



Fig. 42.— Section from tissue in simple chronic rhinitis, showing organization of 
inflammatory tissue. Contraction has not yet taken place, although some areas are 
becoming slightly fibrous. It will be noted that the epithelial layer is somewhat thinned- 
The basement membrane is not demonstrable. The organized tissue shows longitudinal 
and transverse sections of the newly-formed blood-vessels (author's specimen). 



Fig. 43.— Section of tissue in intumescent rhinitis. The connective tissue (submucosa) 
shows round-cell infiltration. The connective-tissue fibers are separated and swollen, 
owing to the watery infiltration. The epithelial cells show somewhat the same swollen 
condition (author's specimen). 
























& ® ^ ft iv #:■ *^ 'a - : V; 




SIMPLE CHRONIC RHINITIS. 109 

derangement from swallowed secretion or improper mastication. 
There is a marked tendency to attacks of acute rhinitis on the 
least exposure ; this is especially true in damp weather. Extended 
cases may develop a redness and congestion of the tip of the nose, 
often transitory and not unlike the beauteous " rum blossom," and 
there may be a swelling of the cutaneous surfaces of the tip and 
alae, with a concomitant acne. On inspection the mucous mem- 
brane will be found diffusely, but slightly, swollen, especially on 
the septum and the middle and inferior turbinates, red, soft, and 
cushion-like, and showing here and there areas covered by secre- 
tion. The membrane is irritable, especially on the septum and 
inferior turbinates, and pits slightly on pressure, the dent slowly 
disappearing. There are certain areas of marked hyperesthesia, and 
the application of cocain causes a slow subsidence of the conges- 
tion, leaving a wrinkled appearance of the mucous membrane. 
In the case of the debilitated and aged, the membrane may be pale 
and covered with a watery secretion. The symptoms, as a whole, 
are less severe than in the acute. The appearance of the mem- 
brane and many of the symptoms of simple chronic rhinitis after the 
proliferation of the connective-tissue elements has taken place and 
before contraction, are almost identical with those of hyperplastic 
rhinitis and the first variety of atrophic rhinitis, and do not 
necessitate repetition. 

Diagnosis. — Usually not difficult, and is based upon the 
history of the case, inspection, and palpation. 

Prognosis. — If untreated, the disease remains stationary or 
becomes hyperplastic or atrophic. Removal of the cause and 
proper treatment, however, offer a fair chance of recovery. The 
condition may recur as a new process. It occasionally is the 
starting point of polyp development, and frequently antecedes a 
severe catarrh of the Eustachian tube. 

Complications. — During the course of the disease the sense 
of smell may be slightly or greatly impaired, and the correlated 
function of taste correspondingly affected. Aural complications 
not infrequently occur through implication of the Eustachian tube 
in the inflammatory process ; or by extension through the nasal 
duct the eye may be affected. The accessory cavities may be in- 
volved. Symptoms of gastric derangement are not uncommon. 

Treatment. — There enter into the treatment of simple chronic 
rhinitis two elements — first, the discovery and elimination of the 
underlying cause ; and second, the relief of the alterations produced 
in the nasal mucosa. By this latter statement is meant that in a 
simple chronic rhinitis depending, for example, upon a uric-acid 
diathesis, or a renal or hepatic lesion affecting the nasal circulation 
by irritation and vascular pressure, there would be produced altera- 
tions in the submucosa and the epithelial layer of the mucous 
membrane. This alteration would persist despite the removal of 



110 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

the cause. Treatment then must be constitutional and local, and 
the result is necessarily controlled by the extent and permanence 
of the alteration. 

Many cases of simple chronic rhinitis, in which the turbinated 
bone, usually the middle, is of the hanging or pendulous variety 
(Fig. 54), hanging down into the nasal cavity, the mucous mem- 
brane being subjected to irritation from all points, thickens as a 
result of slow inflammatory change. This, together with the large 
and spongy turbinate, may necessitate radical treatment. As a 
rule, enlargement is limited to the membrane covering the turbi- 





Fig. 44. Fig. 45. 

Figs. 44 and 45.— Morbid anatomy of cystic turbinates. 

nate bone. If the bone is enlarged, it is usually due to a cystic 
condition as seen in Figs. 44 and 45, and not to any overgrowth 
of bony structure. This cystic condition of the turbinate body, 
especially the middle turbinal, is not so rare as is generally sup- 
posed. The diagnosis can usually be made by palpation. If a 
cystic condition exists within the bone, the mucous membrane is 
usually very thin over the surface of the bone. With the condi- 
tion in which the bone is cystic, certainly the rhinologist is justi- 
fiable in removing the diseased bone, but it should be done by the 
method described on page 111, saving as much mucous membrane 
as is possible and preventing scar-formation. 

Lathrop of Boston, in a paper based upon the study of one 
thousand specimens, states that 9 per cent, of all cases contained a 
cell ; in 1 per cent, both middle turbinates of the same subject 
contained cells, and that they were found slightly more frequent 
in the right than in the left turbinate. The cells were located 
almost without exception somewhere in the anterior half of the 
turbinate. The cell may extend so high as to reach the cribriform 
plate of the ethmoid, and a considerable distance either forward 
or backward. In some instances of these exceedingly large cells he 
found that a probe could be passed from the frontal sinus or the 
frontal bulla directly into the turbinate cell. 

Before the removal of the portion of the turbinate is at- 
tempted, gradual pressure should be used. This can be accom- 




Fig. 46.— Section of cystic turbinate. The section shows a complete cyst with the 
dense wall of tissue surrounding it. The cancellated bone-structure shows outside the 
dense wall of the cyst. The mucous membrane shows on either border of the section. 
There is some slight round-cell infiltration within the connective-tissue element of the 
cyst wall. 



SIMPLE CHRONIC RHINITIS. 



Ill 



plished by means of a malleable silver tube (Fig. 93), which 
can be fitted to the nostril, and pressure increased as desired. In 
the beginning the tube should be worn only a short time, from 
one to two hours, the time being gradually prolonged. Another 
admirable method of reducing the tissue, without leaving a surface- 
scar, is to scrape the turbinate bone by means of a sharp-pointed 
probe. After cocainizing the tissue, make a simple puncture, 
passing the probe directly through the membrane down to the 
periosteum, and, by gently scraping the tissue, sufficient inflam- 
matory process is set up to produce rapid inflammatory change. 
The contracting tissue will rapidly reduce the swelling. Personalty, 
I am opposed to indiscriminate removal of the turbinate or por- 
tions of that body, and in all cases its removal should not be 
attempted save as a last resort, and only when interference with 
nasal breathing is sufficient to demand such radical measures. 

When the obstruction is sufficient to justify removal of a por- 
tion of the bone, the mucous membrane should be dissected up 
from the turbinate and the edge of the bone removed. For the 
incision and the dissection of the membrane, the instruments seen 
in Figs. 47 and 48 are admirable. For the removal of the bone 
any strong alligator bone-forceps may be used. Milbury's bone- 



Fig. 47.— Author's septum-knife. 



Fig. 48— Modified Aseh's knife. 

forceps, which is a modification of Gleitsmann's, is the best 
(Fig. 49). 




Fig. 49.— Milbury's conchotome. 



Enlarged Turbinate Bones. — In the removal of a turbinate 
body a number of points must be considered : First, that it is an 
actual increase in the bony structure and not the mucous membrane. 
Second, equality in space in the two nostrils is vastly important, 



112 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

and in the removal of a turbinal for the relief of an obstruction 
of the nasal cavity this fact must be taken into consideration, so 
that the contraction following the operation will not leave that 
nostril of an abnormal size. Also, it is vastly important to make 
as little scar as possible, as the scar tissue contracts and lessens 
blood-supply not only to the immediate scar, but to the surround- 
ing tissue secretion is interfered with and the individual will have 
crust formation in the area of the scar tissue. This is especially true 
following cauterization. The scar following a burn is always irreg- 
ular and uncontrollable, and while the cauterization may relieve the 
obstruction at the time, yet the after-results will be more disastrous 
and annoying to the patient than the original obstruction. If cau- 
terization is to be used, a sublinear method, as recommended by 
Norval H. Pierce, of Chicago, is the most suitable. Every pre- 
caution should be taken to avoid removing too much tissue, allowing 
for the contraction. Vischel, of San Francisco, recommends the use 
of collodium after removal of the turbinate bodies. His method 
consists, first, in touching the wound several times with an adrenalin 
solution 1 : 1000, to stop the bleeding. He then applies collodium 
over the bleeding surface. The turbinated body should never be 
sacrificed unless it is absolutely necessary for the establishment of 
nasal breathing. 

Constitutional Treatment. — The constitutional treatment 
should be directed toward the eliminating of any lesion which, 
directly or indirectly, affects secretion or circulation. An enu- 
meration of all the possible constitutional lesions that by their 
influence would bring about a chronic rhinitis is of course impos- 
sible ; but an instance is given, with its appropriate treatment, to 
illustrate the point under consideration. For example, if from the 
clinical history of a case it is ascertained that the intestinal tract is 
at fault, due to deficient hepatic and glandular secretion, with the 
accompanying train of digestive and assimilative disturbances, 
there should be administered first a mild purgative, followed by 
decided doses of the granular effervescing phosphate of soda. This 
should be given in one to two tablespoonful doses night and morn- 
ing, and continued until the looseness of the bowels calls for a 
diminishing of the dose. I know of no better drug, if persistently 
used, for the increase of glandular secretion. At the same time, 
tonics should be given, the dosage being controlled by the patient's 
general condition. In addition, there should be administered, 
however, a drug that will increase vascular tone. For this pur- 
pose there is nothing better than sulphate or nitrate of strychnin in 
doses of ^Q-grain three times daily. 

Any peculiar susceptibility on the part of the patient to cold 
on exposure should be guarded against by proper clothing. Also, 
should the exciting factor be a local one, such as exposure to dust 



SIMPLE CHRONIC RHINITIS. 113 

or irritating material of any kind, prompt removal from such ex- 
posure should be insisted upon. 

Local Treatment. — The local treatment should consist in the 
thorough cleansing of the membrane by the use of an alkaline 
solution, such as — 

]^. Sodii biboratis, 
Sodii bicarbonatis, 

Sodii chloratis, 

Potassii bicarbonatis, da gr. xv (.9) ; 

Aquae (tepid.), tisij (60.) ; 

night and morning through the atomizer or Bermingham nasal 
douche. This treatment may be carried out by the patient, and 
the physician should apply every other day to the affected area, 
after cleansing with the above solution and carefully drying the 
membrane, stimulating solutions to meet the requirements in the 
case. The aqueous solution of ichthyol, 20 per cent, to 40 per 
cent., applied by means of a cotton-covered probe ; the compound 
tincture of benzoin and boroglycerid, 50 per cent. ; glycerite of 
tannic acid, 75 per cent. ; alcohol and distilled water, 25 per cent., 
applied in the same manner, are equally beneficial in properly 
selected cases. 

In plethoric individuals stronger astringents are indicated, and 
recourse should be had to nitrate of silver, 4 per cent, to 8 per 
cent. ; sulphocarbolate of zinc, 2 per cent, to 5 per cent. ; chlorid of 
zinc, 3 per cent, to 5 per cent. These solutions should be applied 
every third day until the tissue is sufficiently retracted. In cases 
in which the nasal structure has undergone such permanent altera- 
tion as not to be affected by the astringents mentioned, instead of 
using escharotics or the actual cautery, better results can be ob- 
tained by the incising of the turbinal membrane, making one or 
two cuts parallel to the long axis of the turbinal bones, thus per- 
mitting free depletion. The cut should be made with a sharp 
knife, extending through the entire mucous membrane down to the 
bony structure, and the resulting organized inflammatory tissue 
will be largely limited to the submucosa, preventing the surface-scar 
which follows the use of the actual or galvanocautery or escharotics. 
In this way the tendency to crust-formation is also lessened.- 

Electrolysis will accomplish much in many of these cases. The 
same can be said of kataphoresis ; yet it is only in cases due to 
purely local lesions that this method of treatment is of avail. 

Emphysema of the face may be caused by injury of the tur- 
binated bone. Following injuries, such as blows over the bridge 
of the nose, on account of the suddenness of the shock, the 
mucous membrane may be lacerated over the edge of the tur- 
binated bone. I saw such a case which presented itself at my 
clinic at the Jefferson Medical College Hospital, in which a young 
8 



114 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

man, a basket-ball player, collided with an opposing player. His 
nose bled quite copiously and he blew the nostrils violently, and 
almost instantly the cheek on that side puffed out and he had 
a marked emphysema involving the entire left side of his face. 
Examination of the nasal cavity showed that he had almost a per- 
fectly clean cut, three-fourths the length of the middle turbinate, in 
which the mucous membrane was gaping wide open. The vio- 
lent blowing of the nose had forced the air into the cellular 
tissue, producing emphysema. Continual pressure and rubbing 
gradually forced the air from the tissue and he made an uninter- 
rupted recovery. 

Free nasal breathing is of the greatest import, not only from 
the standpoint of aeration and oxidation of the blood, but also 
for the physiological protection of the accessory cavities. Many 
conditions cause congestion or turgescence of the nasal mucous 
membrane. This is observed in systemic conditions such 
as cardiac, gastric, renal, hepatic, and intestinal lesions, where 
the venous circulation is retarded and there is damming back 
on the venous system with congestion of the lax struc- 
tures. It also occurs in pelvic lesions, such as uterine 
and ovarian diseases, possibly through its reflex relation. 
Newcomb has called attention to a condition in which nasal 
insufficiency was due to an exaggerated prominence of the anterior 
arch of the cervical vertebra. 

The importance of free nasal breathing in its relation to 
hearing cannot be overestimated, as a great many lesions of the 
Eustachian tube and middle ear, later involving the drum, affect- 
ing the hearing, causing tinnitus, etc., the primary cause can be 
traced to nasal obstruction. 

The turgescence of the mucous membrane at puberty in both 
the male and female is well established, and great care should 
be exercised in treating this mucous membrane in children from 
the age of ten to fifteen. In many instances the membrane is de- 
cidedly puffy and very sensitive, and after the child has passed 
through the age of puberty the membrane returns to the normal. 
This condition also exists during pregnancy and the menopause. 
During this period cauterization or removal of this tissue should 
certainly be avoided. 

Lesions of the respiratory tract, bronchial tubes, and lungs will 
also cause congestion of the upper respiratory mucous membrane. 

Gastric diseases, especially perverted chemistry of the secre- 
tion, in which irritants are poured out by the mucous membrane 
glands, also tend to congestion of the nasal mucous membrane. 

Climatic conditions, altitude, exposure to cold and heat, occu- 
pation, sudden changes of temperature, and automobiling are also 
exciting factors. 

Mental excitement and strain, fatigue, and physical exercise, 



IXTUMESCEXT EHIXITIS. 115 

will also produce congestion of this structure. Nervous exhaus- 
tion and physical tire are also casual factors. 

Sexual excitement or excess will also affect the nasal mucous 
membrane and produce passive congestion. 

INTUMESCENT RHINITIS. 

Intumescent rhinitis is not a separate form of disease, but 
merely a different phase of chronic rhinitis, in which in one or 
both nasal cavities there is an extremely sudden swelling, with a 
permanent boggy condition of the mucous membrane. The struct- 
ural alteration is apparently very slight, as at times the membrane 
assumes almost a normal condition. There is during the exacer- 
bation an excessive flow of mucus, at times clear and watery, at 
others more tenacious and mucopurulent. The exacerbation may 
be preceded or accompanied by intense itching due to the irrita- 
tion produced by the vascular change. The cutaneous structures 
of the nose often show engorgement of the vessels, and the skin is 
reddened and rather sensitive. 

Symptoms. — The symptom peculiarly characteristic of this 
affection is the sudden swelling and turgidity of the turbinal and 
septal mucous membrane. The swelling is due to the exudate ; 
w T hile in cyanotic rhinitis it is due to engorged vessels. This 
may occur in both nostrils, or may involve them alternately 
for a varying length of time. After lying down, the lower- 
most side of the nose may be found to be occluded, a con- 
dition which may persist throughout the day or disappear spon- 
taneously within a few hours. There seems to be a peculiar 
liability on the part of the individual affected with this disease to 
take cold, especially during the fall and winter, on the slightest 
exposure. On arising in the morning the voice is often hoarse, 
necessitating a disagreeable hawking to remove the tenacious 
mucus, which often clings so tightly to the soft palate that vomit- 
ing may be induced before the offending material is expelled. 
During the day a hacking cough may be noticed and an irritating 
hoarseness on attempting to sing, requiring effort to clear the voice, 
which readily tires after short exertion. There may be dull frontal 
headache and a tired feeling in the eyes. Dryness and tickling in 
the throat are often met with. Offensive breath, coated tongue, 
gaseous eructations, and digestive disturbances may be found. 

Treatment. — The treatment of this variety of rhinitis is prac- 
tically the same as for simple chronic rhinitis, but the prognosis is 
more favorable. For the intense itching, which is often a great 
source of annoyance to the patient, relief can be afforded by intro- 
ducing into the nostril a pinch of ordinary table salt and allowing 
it to dissolve on the tissue. The external redness may be relieved 
by the application at night and in the morning of water as warm as 
can be comfortably borne by the patient. This should be kept up 



116 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

for ten to fifteen minutes, and the skin patted thoroughly dry with 
a soft towel. 

After the removal of the cause, the mucous membrane can be 
supported by the same pressure-method as recommended under 
Simple Chronic Rhinitis. The size and length of the tubes is 
determined by individual cases. 

HYPERPLASTIC RHINITIS. 

Definition. — A chronic lesion of the nasal mucous membrane 
characterized by permanent localized increase in the nasal mucosa, 
causing more or less obstruction within the nasal cavity. 

Synonyms. — Obstructive rhinitis ; Hypertrophic nasal ca- 
tarrh ; Hypertrophic ozena ; Hypertrophy of the turbinated 
bones ; Chronic hypertrophic rhinitis ; Hypertrophic rhinitis. 

Etiology. — There is considerable difference of opinion in 
regard to the etiology and pathology of the so-called hypertrophic 
rhinitis. Clinically, it is often difficult to differentiate between 
simple chronic rhinitis, intumescent rhinitis, and the so-called 
hypertrophic form (Fig. 51). In certain stages the symptoms of 
each are practically the same, but there is no doubt that the termi- 
nation of the forms mentioned is different and distinct. In the 
true hyperplastic variety the main alteration in structure is an 
increase of the connective-tissue elements of the submucosa. The 
causes which may produce this increase in the connective tissue 
element do not seem to differ much from the causes producing the 
other varieties of inflammation, but in this case the increase is 
more of the order of a hyperplasia. 

When the connective-tissue element is increased, due to an in- 
flammatory process, as a rule it is followed by a contraction. In 
this variety, however, the overgrowth of tissue is almost identical 
with that in a benign tumor, and is not followed by contraction. 
The term hypertrophic or, as I prefer to call it, hyperplastic, 
should be limited to those cases in which the increase of tissue is 
not followed by contraction. It is, indeed, analogous to the so- 
called hypertrophic variety of cirrhosis occurring in the liver. I 
grant that no satisfactory explanation can be given why in certain 
cases it should assume this form, and not in others, yet the same 
may be said of any other hyperplasia. There is no doubt but that 
the hyperplasia or overdevelopment of the connective-tissue ele- 
ment must be brought about by increased blood-supply, as in an 
inflammatory process, or in a modified inflammatory process in 
which the regular microscopical phenomena do not take place. 
This is possible, for example, where the irritation is sufficient to 
keep up hyperemia of the part, the process not going on to con- 
gestion ; the increased nutrition will cause cell-proliferation of the 
then existing connective-tissue element. This process would 
necessarily be slow. The increase in the parts would be identical 




Fig. 50— Section of tissue in hyperplastic rhinitis. The section shows overgrowth of 
connective tissue, which is normal in character and shows no tendency to contract. The 
alteration in the gland-structure is due to pressure from the excessive amount of connec- 
tive tissue. 



HYPERPLASTIC EHIXITIS. 1 1 7 

with a numerical hypertrophy. This increase in tissue may also 
involve the gland-element present, and histologically is identical 
with the normal structure, but falls short in its physiology — that 
is, the new gland-tissue present does not functionate. The tissue 
is fully organized, but fails in function. This variety, the true 
hyperplastic form, is not as common as is generally supposed. The 
interference with the glandular elements of the mucous membrane, 
instead of being brought about by pressure from contraction, is 
due to pressure from excessive amount of the connective-tissue 
element. The condition may be caused by repeated or continued 
attacks of the simple chronic variety, which in turn may be due 
to some irregularity within the nares, either the shape of the 
nostril, malformations, deformities, or deflections of the septum, 
bony growths, irritating snuffs or dusts, etc. Climate does not 
play an important part other than that in localities where there 
are sudden changes of temperature and humidity, in individuals 
having any of the above nasal irregularities the tendency to nasal 
affections is more marked. 

Pathology. — A consideration of the etiology of this subject 
has necessarily involved some of the pathological alterations. The 
morbid histology confirms the statements made above in regard to 
the overgrowth of the connective-tissue element, as well as the in- 
crease in the glandular structure, and the physiology shows the fail- 
ure of function in this new gland-structure. The submucosa shows 
a greater amount of fibrous formation (Fig. 50), the veins and 
arteries are surrounded by thicker connective-tissue support, and the 
venous plexuses are separated by thickened fibrous walls, lessening 
their liability to collapse. In the outer part of the submucosa 
there is an increase in the glandular elements, which, later, gives 
way to a fibrous formation. There is a marked increase in the 
number of capillaries in the tissue. The basement membrane 
shows little or no alteration. The epithelial investment is mark- 
edly thickened, and shows the hyperplasia consequent upon pro- 
longed irritation with sufficient nutriment. The cell-layers are 
greatly increased in number. The outermost layer may or may 
not be ciliated, the underlying layers vary in their cellular size, 
and the lower layer is of quite large, columnar epithelium. This 
upper stratum of the mucous membrane is everywhere thrown into 
folds and furrows, thus greatly enlarging the free surface. In- 
spection shows a lobulated, uneven membrane, which does not pit, 
but indents, on pressure, most marked in the membrane covering 
the middle turbinate, the anterior portion of the superior, and the 
posterior portion of the inferior turbinate. 

Symptoms. — The symptoms of hyperplastic rhinitis are not 
in themselves characteristic. By this is meant that the same 
symptoms may be met with in certain stages of simple chronic 
rhinitis, intumescent rhinitis, and the form due to cyanotic con- 
gestion, as well as the condition presented in plethoric individuals. 



118 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

It must be remembered that the symptoms described are those 
produced by an excess of tissue, and not strictly by an inflamma- 
tory process. 

The condition may involve both nostrils or may be limited to 
one, may involve either the front or the back of the turbinal 
mucous membrane or its entire surface, and is a markedly slow 
process. The color of the membrane cannot be accurately de- 
scribed, as it varies with the stage or degree of the process. There 
is an irregular discharge, sometimes profuse, at other times scanty ; 
the secretion is altered in character. The disease in its true form 
usually occurs in individuals otherwise healthy. It must also be 
remembered that inflammatory processes may secondarily involve 
this hyperplastic tissue, a fact which would naturally complicate 
the symptoms. There may or may not be associated actual in- 
crease in the turbinated bone. The condition is frequently asso- 
ciated with deflection, exostosis, or enchondrosis of the septum. 
The thickened mucous membrane at times resembles a fibrous 
polyp — indeed, may be easily mistaken for such a condition. 
There is marked interference with nasal respiration ; the membrane 
tends to sudden engorgement on the slightest irritation ; any posi- 
tion which favors gravitation increases the distention. As the 
hyperplasia is limited to certain areas only, there is still remaining 
a certain amount of nasal mucosa, which, aside from the local 
irritation, is not involved in the process. This tissue, however, is 
the site of engorgement, and the nasal obstruction with the retained 
secretion necessarily produces irritation and simple inflammatory 
phenomena, with the usual chain of symptoms. The permanent 
'nasal obstruction, often worse at night than in the day, leads to 
habitual mouth-breathing, and the patient frequently acquires a 
gawky, staring appearance, due to his wide-open mouth. The 
secretion is thick, tenacious, and difficult of removal, even though 
it is scanty. The membrane, from involvement of peripheral- 
nerve filaments, loses its sensibility largely, and the sense of smell 
may be markedly impaired or destroyed. The hyperplastic tissue 
at different stages presents varying appearances in different sites, 
and, in describing it, it will perhaps be more convenient to refer to 
the anterior, middle, and posterior hyperplasias, according to 
their localities. In the anterior regions the color of the tissue 
may be nearly normal, or red, varying with the severity of the 
process. The anterior end of the inferior turbinate is swollen, 
and presents a surface which may be smooth, or lobulated, or in 
some cases somewhat foliated. It may even be so swollen as to 
touch the septum. The same is true of the middle turbinate, the 
hyperplasia being mostly on its anterior border, or fore part of 
the inferior border, and red, smooth, nodular, or glandular, as the 
case may be. The membrane of the septum, as a whole, is un- 
evenly swollen, with irregular areas of marked elevation, usually 
most frequent in the lower part. In the posterior enlargements 



HYPERPLASTIC RHINITIS. 119 

the inferior turbinate plays usually the largest part, and posterior 
rhinoscopy reveals a rounded whitish tumor, irregularly crossed 
and fissured, or even lobulated. The same structure may be seen 
in the middle turbinate, but usually smaller and more spindle- 
shaped. These overgrowths may partially or completely fill the 
choanse, or may even project so as to obstruct the orifice of the 
Eustachian tube. Instead of this pale structure there may be 
seen another, usually regarded as an earlier stage of its develop- 
ment, and termed the raspberry or mulberry form. This is dark 
red or purplish in hue, and has a tendency to bleed on slight 
irritation. Both of these structures may occur on the posterior 
portion of the septum. In the middle region the hyperplasia 
is found on the same structures as in the anterior and posterior, 
the middle and inferior turbinated surfaces being red, smooth, 
or granular and rough. Often pedunculated processes may de- 
pend from them, and formations like papillomata may occur. The 
septum may show a longitudinal groove, or grooves, from the 
pressure of the impinging turbinates, and in the anterior regions 
myxomatous formation not infrequently occurs. The superior 
turbinates and roofs of the fossae, as a rule, are slightly or not at 
all involved in the overgrowth — an important fact to recall in the 
diagnosis of polypi. When, however, they do become implicated 
in the process, various eye-lesions seem to be peculiarly asso- 
ciated. Both nasal fossae are usually symmetrically involved, or 
only one may be affected. Or one nasal chamber or area may show 
the hyperplastic development, while the other is normal, or in the 
acute, or simple chronic, or, perhaps, atrophic stage. 

The timbre of the voice is altered owing to the interference 
with nasal resonance. If the middle turbinate is involved, there 
will be occlusion of the lacrimal canal, which on the slightest ex- 
posure will produce conjunctival irritation with watery overflow. 
If the posterior portion of the middle and inferior turbinates is 
involved, there will be impairment of hearing, owing to the occlu- 
sion of the Eustachian orifice. There will be dull, intermittent, 
frontal headache. The overstimulation of the glandular element 
will give hypersecretion of not only the anterior but also the pos- 
terior nasal membrane. There may be accumulation of secretion 
in the nasal cavity, owing to the irregular surface and the altered 
character of the secretion. This, becoming infected with sapro- 
phytic bacteria, may become offensive. This irritating secretion 
passing into the nasopharynx may produce cough. The appearance 
of the true hyperplastic tissue is usually red or purplish, and, when 
it presents the whitish or grayish appearance, it is undergoing 
mucoid degeneration. There is often a sense of fulness and press- 
ure over the bridge of the nose, associated with some face-ache. 
There may be associated with the condition nasal polyps. 

Diagnosis. — The diagnosis of hyperplastic rhinitis is impor- 
tant for this reason, that, in the simple chronic, the intumescent, 



120 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

the cyanotic variety, and the engorgement of mucous membrane 
found in plethoric individuals, while presenting very much the 
same condition and appearance on inspection, the treatment is 
radically different, as the object should be to save the mucous 
membrane and produce as little scar as possible ; for in the true 
hyperplastic rhinitis there can be no return to the normal function 
of the mucous membrane, while in the other varieties mentioned, 
by the proper treatment such results can be obtained. In the 
hyperplastic form, the main object is to restore proper nasal breath- 
ing by the removal of the thickened tissue, thereby allowing the 
normal elements yet remaining and not involved to functionate 
properly. On the application of cocain or adrenalin chlorid there 
is marked reduction in all the varieties except the hyperplastic, 
and in that the contraction is only slight, simply relieving the sur- 
face engorgement. Another diagnostic procedure is based on the 
relative promptness of resumption of shape by the turbinal tissue. 
If, without cocainization, a probe is pressed with sufficient force 
on the affected area, it will, if the condition is found to be one of 
true hyperplasia, leave its impression for some time, the indenta- 
tion slowly filling in ; if the condition be one of simple chronic or 
intumescent rhinitis, as soon as the pressure is removed the tissue 
rebounds to its original shape (Fig. 51). 




Fig. 51.— Left nostril shows hyperplastic tissue, yielding only slightly to probe-pal- 
pation. Right side shows the pitting noted both in simple chronic and intumescent 
rhinitis on probe-palpation. 

Prognosis. — With surgical interference the prognosis is good,, 
as regards the relief of the patient. While it cannot be hoped to 
restore the entire mucous surface to normal, yet, by the removal of 
the excessive growth involving certain areas, and by the estab- 
lishing of nasal breathing, there may be sufficient of the normal 



HYPERPLASTIC RHINITIS. 



121 



mucous membrane left to keep up in a great measure the proper 
nasal functions. 

Complications. — A nasopharyngitis, or pharyngitis — or both 
— tracheitis, or bronchitis are almost sure to accompany the nasal 
condition. Reflex attacks of epilepsy, asthma, chorea, spasms of 
glottis, various eye-complications, such as optic neuritis and forms 
of headache, mental hebetude, different manifestations of aprosexia, 
and, perhaps, amnesia may occur. The lowered tone or loss of the 
olfactory or aural functions has been referred to as quite sympto- 
matic, and middle-ear catarrh is not uncommon. Occlusion of the 
nasal duct may produce a conjunctivitis or epiphora. Obstruction 
of the sinus outlets may cause mucocele, or, if infection be present, 
suppurative processes. Deafness from Eustachian involvement 
and, frequently, an associated nasopharyngitis are present, with 
a relaxed velum palati and uvula. Digestive disturbances are 
extremely common, and are exhibited both as local and constitu- 
tional effects. Locally, various forms of tumors, especially polyps, 
and, in the nasopharynx, adenoid growths, may develop. 

Treatment. — Locally, cleansing solutions should be applied, 
not so much for their curative effect, as to rid the nostril of any 
retained secretion and keep the part as thoroughly cleansed as pos- 
sible. The curative treatment consists in the removal of the 




Fig. 52. — Alligator-jaw forceps. 



if 




Fig. 53.— Author's nasal saw— double cutting edge. 



excess of tissue. This can be done by means of acid or the gal- 
vanocautery. Personally, I prefer excision with the knife shown 
in Fig. 47. A wedge-shaped incision may be made, and the 
excess of tissue removed either by the saw-scissors or the snare- 
loop, and the resulting scar will be thereby lessened in extent. 
Should there be thickening of the turbinate bone or any ten- 



122 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

dency to shelving or hanging of the bone after the removal of 
the tissue, the mucous membrane should be dissected away from 
the bony surface, and the edge of the bone removed by means of 
the alligator-biting forceps (Fig. 52) or the nasal saw (Fig. 53). 

For the removal of redundant tissue my procedure has been to 
select the most dependent part of the overgrowth or that part most 
prominent in causing obstruction or irritation. The site being 
chosen, I make a V-shaped incision with the knife shown in Fig. 
47, cutting away from the septum and causing the two areas of the 
V to intersect at a fixed point on the turbinal bone, including by 
its removal as much tissue as will free the nostril and relieve irri- 
tation. When the incisions are made, if the excised portion cannot 
be removed, it is cut free with the saw-scissors (see Fig. 76, page 
249). The V-shaped gap in the turbinal tissue will now close on 
itself, and the union will leave on the surface a linear scar only, 
parallel to the long axis of the bone. After the operation the 
nostril should be kept carefully cleansed by the use of — 

1^. Sodii biboratis, 
Sodii bicarbonatis, 
Sodii chloratis, act z] (3.6) ; 

Aquae, fl3iv(120.) 

every three hours, in a Bermingham nasal douche. 

If the offending tissue is corrugated or sessile, I prefer to 
remove it en masse with the cold snare. Fitting the loop closely 
about the tissue to be removed, tighten it by two or three turns, 
then wait a few moments ; again twist the wire still tighter, wait 
a short time, and repeat the procedure until the snare has com- 
pletely severed the mass. By proceeding in this way the danger 
of hemorrhage is minimized. The stump should be cauterized 
with the galvanocautery, or chromic acid fused on the point of a 
probe. After the operation, cleanse the cavity daily with the solu- 
tion given above. Tissue may also be removed by the electro- 
cautery snare more rapidly than with the cold-wire snare. The 
reactionary contraction to linear cauterization of the offending tur- 
binate will often widen the cavity sufficient for ordinary breathing 
purposes, and thus give relief. 

Electrolysis, using the bipolar method and preferably a double 
electrolytic needle, has given very favorable results. A current 
of from 5 to 10 milliamperes, gradually admitted and as gradually 
diminished, will in from two to five minutes effect the desired re- 
sult. The points in favor of this method of treatment as against 
other methods have been well summarized by Scheppegrell, and 
are that it is a conserver of tissue ; that it is, at least, not more 
painful than any other ; there is little reaction, and, finally, that, 
being submucous, there is no danger of synechia. 



OZENA. 123 

OZENA. 

It has seemed advisable to the author, in view of the ofttimes 
perplexing employment of this term by medical writers, to give 
a little space to a consideration of its proper limitation. The 
term itself, as derived from the Greek o^aiva, signifies properly a 
stench, and has had its place in medical nomenclature from far 
remote times. The early Greek and Roman writers, however, did 
not restrict the term to a fetid odor merely, but used it as includ- 
ing both the odor and an associated ulcer. Later in the history 
of medicine it was used as a synonym of a nasal ulcer, whether 
fetid or not, and this application seems to have been accepted gen- 
erally for a long period. In the twelfth century, however, one 
writer departed from this and described the condition as due to a 
decomposition of secretions, not mentioning ulceration in the same 
connection, and in the seventeenth century again this same opinion 
was expressed. It is little wonder, then, that a word with such a 
history should in the present time stand ready to represent indif- 
ferently, at the will of the writer, either a disease or a symptom. 
But ozena is not in any sense a true disease in itself ; its peculiar 
place is that of a symptom, and in no other light can it properly 
be regarded. It bears to certain diseases of the respiratory tract 
precisely the same relation that the rash does to the eruptive fevers, 
and, like the rash, it varies in character and intensity in accord- 
ance with the graver disease with which it is associated. It 
is just as proper intrinsically to speak of a rash as a disease 
always attended with measles, for example, as it is to speak of 
ozena as a disease, when the presence of a graver malady is only 
too evident. Thus the terrible sickening odor of atrophic rhi- 
nitis may be so intense as to constitute practically the sufferer's main 
trouble, and yet we scarcely think that it would be strictly right 
to speak of ozena with an attendant atrophy of the nasal mem- 
brane. The same is true of the ozena present in syphilis, in sup- 
purative processes of the accessory sinuses, in glanders, in coryza 
caseosa, in certain neoplasms — malignant or benign — in congenital 
malformation of the nasal spaces, and in some cases of an occlud- 
ing foreign body, in all of which conditions it plays the simple, 
more or less important role of a symptom. 

Ozena displays, in the different conditions in which it occurs, a 
considerable variation in its manifestations. It may be extreme, 
almost overpowering, or it may constitute but a slight annoyance 
from continued presence. It may be perceptible to the patient 
and not to those near him, or vice versa ; may be unilateral or 
bilateral, constant or intermittent, and may disappear by applica- 
tion of disinfectants, or show no reaction to their presence. As 
to the causation, there is little that can said with certainty. 
Upon this phase of the subject, speculation and theory have been 



124 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

given full rein. The growth and development of bacteriology, 
which has given the solution to so many formerly obscure etiolo- 
gies, would seem to have given no more than a clue in this case. 
Nay, it even leads into confusion, if we accept a bacterial causa- 
tion, as to whether it is the result of a saprophytic decomposition 
of secretions, or, in some particular cases, whether the odor be not 
the peculiar product of some specific germ — alone, it may be, or 
in combination with the former. Certainly no better life-condi- 
tions could be found for germ-growth than the warm, moist secre- 
tions of the nasal cavities. A second theory has been advanced — ■ 
namely, that it is due to a product of fermentative changes in the 
secretion. Another theory, based upon pathological retrogressions 
in tissue, claims that the odor is a combination of various fatty 
acids, set free in the decomposition of fat resultant from a fatty 
cellular degeneration. A fourth theory expresses the hypothesis 
that the odor in each case is sui generis, an entity which belongs 
to each underlying condition as its peculiar attribute. Personally, 
I believe that the action of the saprophytic bacteria seems to offer 
the most rational single view, and finds corroboration both clini- 
cally and theoretically. Moreover, if we go a step further and 
study the putrefactive processes taking place in certain other in- 
fected conditions, as, for example, pulmonary abscess, or gangrene, 
we find exhibited on a larger scale the same conditions and the 
same results which obtain in the diseases already mentioned as 
attended with ozena. Especially is the characteristic odor which 
accompanies the latter conditions similar to that of ozena. But 
yet with this proof, in the present condition of uncertainty, we 
must not accept it as the sole explanation. It is possible, or, per- 
haps better, it is probable, that ozena may in a given case be due 
not to one cause, but to a combination. For example, the ozena 
in atrophic rhinitis may be attendant upon putrescent secretion, 
and the fetid odor of nasal syphilis may be the expression of a 
factor as yet unknown, possibly acting alone, or in combination 
with decomposition. I have seen a number of cases of apparent 
ozena in which the cause was entirely dental ; the incisors, one or 
both, being diseased, had, by extension of the degenerative proc- 
ess by contiguity of structure, involved the floor of the nose, and 
the odor emanated from the necrotic tissue, and the nasal odor 
was due entirely to this process. Again, in several instances 
where, from decomposition at the root of a tooth extending into 
the antrum of Highmore, gases from such tissue-decomposition 
accumulated and escaped through the nostril, the odor was that as 
noted in atrophic rhinitis. In the majority of cases of ozena due 
to lesion of the nasal mucous membrane, the patient has entirely 
lost the sense of smell. This is a point in diagnosis as to the 
source of the odor ; if the patient can detect the odor, then the 



ATROPHIC RHINITIS. 125 

ozena is due to some local ulceration or involvement of some of 
the accessory cavities, or a spot of necrosis of the mucous 
membrane, bone, or cartilage, while if they cannot detect the 
odor it shows involvement of the mucous membrane. It has been 
observed that a number of patients suffering from ozena have 
developed tuberculosis. This does not mean that there is any 
relation between the two conditions, but an individual who 
suffered from ozena due to a mucous membrane disease necessarily 
would have lowered cell resistance and would be predisposed to 
infection. But, however originating, the essential fact must not 
be overlooked that ozena is in no true sense a disease, but is solely 
a symptom. 

ATROPHIC RHINITIS. 

Synonyms. — Atrophic catarrh ; Atrophic nasal catarrh ; 
Chronic atrophic rhinitis ; Chronic fetid rhinitis ; Cirrhotic rhi- 
nitis ; Dry catarrh ; Dry nasal catarrh ; Dysodia ; Fetid atrophic 
rhinitis ; Fetid catarrh ; Fetid coryza ; Fetid rhinitis ; Idiopathic 
or constitutional ozena ; Ozena ; Rhinitis atrophica ; Rhinitis atroph- 
ica simplex ; Rhinitis fcetida atrophica ; Rhinitis sicca ; Sclerotic 
rhinitis ; Simple ozena ; Atrophic endorhinitis. 

Classification. — Atrophic rhinitis is in reality not a separate 
process nor an inflammatory condition, but the result of pre-exist- 
ing conditions, and as to cause may be divided as follows : 

First, an atrophy of the nasal mucous membrane which is 
brought about by a pre-existing inflammatory process followed by 
contraction (Fig. 55), which necessarily lessens the blood-supply 
to the part — a fact which in itself will tend to cause atrophy, 
and also, by pressure, to lessen the function of the glandular ele- 
ments present. 

Second, an atrophic process which is truly a pressure-atrophy 
brought about by overdistention of the blood-vessels of the sub- 
mucosa, not due to any local obstruction, but interference in the 
systemic circulation, by which the blood is dammed back on the 
mucous surface, and by the pressure thereby produced there is 
caused atrophy of the connective-tissue and glandular elements 
(Fig. 57). It is pathologically a cyanotic congestion and a press- 
ure-atrophy, and is identical with the condition seen in red atro- 
phy of the liver. 

Third, an atrophic rhinitis which is a simple atrophy or a 
trophic process. 

It will be seen that the above arrangement differs from the 
classification given in most works on diseases of the nose and 
throat, yet it is based on clinical observations and the knowledge 
of the pathological alterations of the structure, and while the 
result of the atrophic process when completed is practically the 



126 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

same regardless of cause, yet the pathology and treatment of such 
alterations would necessarily be different. For convenience, 
atrophic rhinitis may be divided as follows : 

(1) Primary, or a direct lesion of the part, such as a simple 
atrophy or a trophic process. 

(2) Secondary, or atrophy as a result of (a) pre-existing local 
lesion in which, as a result of this lesion, there is atrophy of the 
membrane, and (b) atrophy which is secondary to a lesion some- 
where else, or, in other words, a condition which is forced upon 
the membrane — a pressure-atrophy. 

General Remarks. — It must be remembered that atrophy 
and degeneration are separate processes ; also, that in simple atro- 
phy of a part there is diminution in nutrition, with lessened func- 
tion, though not necessarily lessened size, for the size may be in- 
creased owing to fluid distention, as is shown in red atrophy of the 
liver, nevertheless the structural element is lessened. In simple 
atrophy there is a reduction in the size of the cellular elements, 
and possibly a numerical reduction, but there is still present the 
individual cell, which by improved nutrition and improved func- 
tion may be restored to its proper condition ; while in degeneration 
there is an entire loss of function, the then existing cell is con- 
verted into another material, and there is no possible return to the 
normal. I believe then, in atrophic rhinitis so-called, that in 
certain stages the tissue is simply atrophied, and, if the cause can 
be removed and nutrition established, it might be brought back to 
the normal. Unfortunately the cause can rarely be removed, 
and the condition goes on to a degenerative process, which explains 
the fact that it is rarely cured. To use the term "atrophy 
with degeneration " is incorrect ; it should be " atrophy followed 
by degeneration," as the processes are separate and distinct. True, 
degeneration may be, and frequently is, secondary to the process 
of atrophy, but it is possible to have a degeneration not preceded 
by the process of atrophy. There seems to be an idea prevalent 
that the connective-tissue element is the first to suffer, but this I 
do not believe to be true. While it may be the first involved, it 
is a well-known anatomical and physiological fact that the con- 
nective-tissue element is the essential and independent structure ; 
also, that connective tissue can exist without epithelial cells, 
but that epithelial cells are dependent structures, and cannot exist 
without connective-tissue basement-membrane support. Now, if 
any alteration takes place in the submucosa, which is the essential 
structure — that structure which commands and controls nutrition 
— and is, of course, the first altered, the tissue farthest from nutri- 
tion would be the first to suffer — that is, the epithelial cells. I 
grant that the change is largely one of degeneration, which is sec- 
ondary to the atrophy, and the term cirrhosis (meaning a fatty 
degeneration or fatty change) and the term sclerosis (meaning a 




Fig. 54.— Hanging turbinate as seen in various forms of rhinitis. It acts as a mechan- 
ical obstruction in causing congestion above and below, and thus doubly obstructs the 
nasal cavity. 




Fig. 55.— The left nostril shows the morbid anatomy of atrophic rhinitis ; the right nostril 
shows the appearance of simple chronic rhinitis before contraction. 



ATROPHIC RHINITIS. 127 

hardening) are both correct, but the cirrhosis or fatty change fol- 
lows the sclerosis. Now, in the consideration of the atrophic proc- 
esses, we must distinctly remember that the condition is con- 
stantly changing — that, in reality, it is a termination of other con- 
ditions, a resulting state with definite structural changes; and 
as to whether it be called atrophy or whether it be called 
degeneration depends entirely on the stage of the pathological 
alteration ; that is, if this alteration can be arrested while it is 
still an atrophic process, a fair amount of function may be re- 
stored ; but if it has gone on to a lower retrograde change, that of 
degeneration, then the cell-function can never be restored. 

Too much stress has been laid on the various forms of atrophy, 
which has only added to the confusion of classification and the 
multiplicity of terms. It makes no difference, in the actual proc- 
ess in the tissue, whether an atrophy be primary or secondary ; 
the atrophic change is the same. The causes may be different, and 
in some cases, as in a pressure-atrophy from inflammatory contrac- 
tion, the process cannot be arrested while it still exists as an 
atrophy ; and, although the process is the same, in an atrophy 
from lessened nutrition, if nutrition be supplied, the tissue may 
again return to the normal, but the atrophic condition as it existed 
is identical with any other atrophy. 

The variety of rhinitis often described as atrophic is usually 
that which follows the simple chronic variety (Fig. 57), and not 
the hyperplastic variety. The process does not begin as one of 
atrophy, for, when it reaches the point of atrophy, it is really not 
an inflammatory process at all, but simply a result ; and the changes 
which take place in the structure — the cirrhosis, the desquamation, 
the involvement of gland-structure, with atrophy and degeneration 
— are due to the facts that the nutrition is cut off by the sclerotic 
or fibroid change, and that the atrophy has gone on to a further 
retrograde change, that of degeneration. 

The fact that — in the varieties of atrophic rhinitis with much 
shrinking of tissue with the wide-open nostril, the irregular cavity 
showing almost as if the bony walls were exposed — there is very 
little bleeding if irritation is produced, confirms the theory of 
fibrous-tissue formation with contraction, as the fibroid contraction 
would lessen the blood-supply and thereby lessen vascularity and 
tendency to bleed. I have seen ulcers in several cases of this ad- 
vanced variety which were brought about by degenerative proc- 
esses, and from which there was practically no bleeding unless 
considerable irritation was produced. 

Atrophic rhinitis in children begins usually from the sixth to 
the tenth year. Since much of the blood-supply comes to the 
nasal cavity through bony foramina, it is possible that up to 
that stage of development the foramina permit of sufficient 
blood-supply to sustain the part, but as development occurs the 



128 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

lumen of the bony exit may be decreased, or, rather, not develop 
with the increase in blood-supply, thereby furnishing insufficient 
nourishment to the nasal mucous membrane. This, I think, 
would account for the atrophic condition in such cases. 




Fig. 56.— Concave nasal floor (after Cryer). The flat palatal arch causes the nasal floor 
to he concave instead of flat, as it otherwise would be. Here secretions collect and crusts 
form, causing ulceration ; or else the secretion runs posteriorly instead of draining for- 
ward, and thus sets up a nasopharyngitis. 

Much has been said in regard to the atrophy of the turbinal 
bones in atrophic rhinitis. Some of the cases of apparent bone- 
atrophy may be explained by the fact that the turbinated bones 
may have been rudimentary, or were of arrested development. 
In comparing the shrunken and apparently atrophied bones seen 
in cases of atrophic rhinitis with the appearance presented by the 
cadaver in the anatomical rooms, I find there is very little differ- 
ence, and the apparent diminution is largely confined to the mucous 
membrane covering these bones. Absorption of bone may take 
place, but in order to have absorption of a bony structure there would 
necessarily have to be marked alteration in surrounding structure, 
which alteration would be degenerative. In some cases there is 
unquestionably bone-involvement ; but, when such a process takes 
place, if a careful clinical history be obtained, it will be found 
that there are present tuberculous or syphilitic conditions. I 
insist on the separation of the terms atrophy and degeneration, 
because the simple atrophy without degeneration may be restored 
to the normal ; but, when degeneration takes place, the process is 
separate and distinct, and the tissue which has actually degenerated 
cannot return to the normal. The reason that atrophic rhinitis is 
so difficult of cure is that the process of atrophy has in many cases 



ATROPHIC RHINITIS. 129 

progressed to one of degeneration, and there is no restoration pos- 
sible. 

In cases in which ozena is the prominent symptom, in which there 
is practically little or no alteration in the nasal mucous membrane, 
and yet a frightful and persistent odor is present, the source of the 
same is, in the majority of the cases, from one or more of the acces- 
sory sinuses. The odor and the atrophic inflammatory change which 
occurs in the nasal mucous membrane may be due to the fact that, 
in the bony formation of the floor of the nose, the bony wall assumes 
a concavity (Fig. 56), in which there is a natural tendency to the 
accumulation of secretion. These inflammatory secretions by the 
continuous irritation will produce inflammatory tissue-alteration. 
Indeed, this explains some cases in which there have been ulcera- 
tion and perforation of the hard palate. In all such cases it will 
be found that the bony wall was very thin at that point, owing to 
the concave formation. 

Atrophy Due to a Pre-existing Local Lesion. 

Etiology. — As this variety follows inflammatory processes, 
either simple or infective, the causes would necessarily be those 
which would produce simple inflammatory processes of the mucous 
membrane, such as are given under traumatic rhinitis, simple 
chronic rhinitis, and the membranous varieties. Malformations, 
nasal deflections, septal spurs, ill-formed nasal orifices, imperfectly 
developed turbinates, all act as predisposing factors. The heredi- 
tary tendency supposed to exist in some families can be explained 
by the inherited family nose, which, owing to its shape, predisposes 
to nasal inflammation. There should be classed here those varie- 
ties which are due to, or associated with, infectious inflammatory 
processes, in which there is not only involvement of the sub- 
mucosa, but also permanent alteration of the epithelial layer. 
Other exciting causes are the infectious diseases, such as measles, 
diphtheria, scarlet fever, and, occasionally, typhoid fever. The 
condition is also subsequent to chronic catarrh of the frontal, 
ethmoidal, or sphenoidal sinuses, especially the last, or to an 
involvement of the antrum of Highmore, either by infection from 
the nose, or in most cases associated with carious teeth. The 
variety of atrophic rhinitis following simple chronic purulent 
rhinitis, which undoubtedly produces atrophic processes, should 
be classed here. 

The age of the individual at which this condition may occur is 
usually under thirty, although it may be found in the very young 
or in adult life. In my own experience I find little difference as 
to sex. 

The simple dry rhinitis of the aged I do not believe should be 
classed as an atrophic process, other than that with advanced age 
9 



130 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

we find a lessened physiological function of the entire body, and 
that the atrophic process occurring in the nose, with the altered 
secretions, is nothing more than the physiological alteration of old 
age. 

I have seen several cases of dry rhinitis in young persons, 
which I believe were entirely due to the action of Vapors inhaled, 
the glazing of the surface and the dryness being produced by the 
alteration in secretion caused by the action of the pernicious fumes. 

Two cases which lived in close proximity to gas-tanks were 
entirely relieved of the condition by removal to other localities. 

Micro-organisms. — As to the micro-organisms present, Lowen- 
berg and Frankel, Abel, Hajek, and others have described special 
bacteria. While they may be associated or in some way con- 
nected with the ozena so often found, yet I do not believe they 
are specific etiological factors. In oculations made from 30 
cases of advanced atrophic rhinitis I have found no special micro- 
organisms present, but have been able to demonstrate a number of 
the pathogenic bacteria. FrankeFs pneumococcus, Klebs-Loffler 
bacillus, Tubercle bacillus, Bacillus foetidus, and various varieties 
of strepto- and staphylococci were found. I think the micro- 
organisms present, instead of being an etiological factor, are 
merely concomitant and of no pathological significance. 

Cobb reports on cultures taken from 90 cases of atrophic rhini- 
tis, all of which yielded pure cultures of the atrophic bacillus, or 
the Bacillus mucosus ozena? described by Abel. 

Pathology. — The pathological alterations in the mucous mem- 
brane which are the result of the simple chronic inflammatory 
process show in the submucosa an overproduction of connective- 
tissue element, which, being inflammatory in origin, follows the 
rule of newly formed inflammatory connective tissue, and con- 
tracts (Fig. 57). Up to this point it is not truly an atrophic con- 
dition, and is nothing more than a simple chronic, inflammatory 
process, with organization. With the contraction, there is an 
interference with the blood-supply not only of the newly formed 
tissue, but of the entire structural element. As well as interference 
with nutrition, there is also pressure involving the gland-elements, 
which, together with the limited nutrition, brings about atrophy. 

We have seen, in the study of simple chronic rhinitis, that 
the thickened membrane was due to the organization of the cellular 
infiltration and proliferation, and the production of interstitial in- 
flammatory tissue. This inflammatory tissue, the chief cause of 
the overgrowth in that condition, plays in the atrophic form as 
well, the chief, though diametrically opposite, role. From the 
pathological view of the disease we must, in the great majority of 
cases, regard it as the final stage of a continuous process, of which 
the simple acute and the simple chronic are the precedent steps. 
Such a view, moreover, finds in the dominant characteristic of in- 




Fig. 57. 



Fig. 58. 




Fig. 59. 



Fig. 60. 



Fig. 57.— Atrophic rhinitis due to fibrous contraction, showing the effect on glands and 
vessels: a, mucous membrane; b, point of denudation; c, distortion of glands due to 
pressure by contracting fibrous tissue ; d, fibrous tissue. 

Fig. 58. — Same conditions as in Fig. 57, only more advanced : a, area of denudation, 
due to diminished blood-supply caused by contracting fibrous tissue : o, atrophied glands. 

Fig. 59.— Showing the fibrous tissue of Fig. 58 under higher magnification. 

Fig. 60.— Atrophic rhinitis due to cyanotic congestion: a, dilated veins; b, gland- 
tissue ; c, arteries. 



ATROPHIC RHINITIS. 131 

flammatory tissue — namely, its tendency to contraction — an ade- 
quate explanation for all the phenomena exhibited, both in 
structure and symptoms. The process is gradual, and usually 
uneven in its development. The slow contraction, by its pressure, 
lessens, then cuts off nutrient supply — first, the capillaries, then 
the larger arterial twigs, and the venous plexuses themselves 
become narrowed and partially or completely obliterated. As a 
result of this impaired nutrition, the epithelial cells undergo cloudy 
swelling, granular or even fatty degeneration, and are cast off in 
great abundance. The epithelium of the glands shows similar 
retrograde changes, and their secretion alters its character, becomes 
more albuminous and tenacious, and forms a suitable base for the 
formation of crusts and nidus for germ-growth. The same changes 
may occur in the cellular elements of the deeper layers of the mem- 
brane (Figs. 58, 59) ; the cells undergo cloudy and granular change 
or fatty metamorphosis. Inflammatory proliferation is still in prog- 
ress, but the lessened nutrition prohibits organization, and the cells 
eventually break down and are removed by the vascular and lym- 
phatic channels. The bony framework, especially of the two lower 
turbinates, may undergo a slight rarefying osteitis, with consequent 
lessening in size. This, however, seems to be dependent upon con- 
stitutional conditions influencing the atrophy, rather than upon local 
causes. The ultimate result of these changes is a membrane which 
resembles a cutaneous structure more than a mucous membrane. 
The epithelium is scanty and of cuboidal or flat shape, and a certain 
amount of granular debris, marking the desquamation and destruc- 
tion of cells, is present. The basement membrane is relatively 
less involved. The submucosa shows a marked lessening and 
alteration of structure. In its external portion the glandular for- 
mations are largely or quite obliterated, the blood-vessels are 
scanty or lacking, or the few present have markedly thickened 
walls. (See Figs. 57-59.) There is a certain amount of round-celled 
infiltration present and granular debris ; fat globules and particles 
of pigment may be demonstrated under the microscope. In the 
deeper region the structure is fibrous, but not so markedly con- 
tracted. The venous sinuses, as a rule, are totally obliterated. 

The variety due to infectious inflammatory processes gives very 
much the same pathology as is mentioned above, except that there 
is a primary involvement of the epithelial surface. The altera- 
tions are more rapid and the atrophy more pronounced, owing to 
the fact that it is associated with generally poor nutrition. There 
is then the combined process of early inflammatory organization 
with contraction, associated with local infection. By the spread- 
ing of the inflammatory process by continuity and contiguity of 
structure, there may be involvement of the pharyngeal and laryn- 
geal tonsils and the glands in the posterior pharyngeal wall. 



132 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

Symptoms. —There is a history of pre-existing catarrhal con- 
ditions, which may be associated with nasal irregularities, and in the 
early stage give the same symptoms as the advanced simple chronic 
rhinitis before contraction. As the process goes on to atrophy, the 
patient will complain of irregular secretion, with a tendency to form 
crusts within the. nasal cavity. These crusts or " slugs " can for a 
time be easily removed, but as the process progresses, and as the 
accumulated secretions become infected to a greater or less degree 
by saprophytic bacteria with increased degeneration, there is a ten- 
dency for the crusts to become more adherent and difficult of re- 
moval. Ulceration of the septum, which sometimes occurs, I 
think is often due to the patient picking the nose, necessitated by 
the sensation produced by the accumulated secretion. The mucous 
membrane will present an irregular surface with varying shades 
of color (Fig. 55). The tissue in which the contraction is occur- 
ring is white or grayish in color, while the tissue which is not 
involved is boggy and slightly edematous. The anterior portion 
of the inferior turbinate and the anterior and middle portions of 
the middle turbinate are the surfaces usually involved. This 
variety of atrophic rhinitis may or may not be accompanied by 
odor, depending upon the ability of the individual to keep the 
nostrils free from accumulated secretions, as the inspissated mate- 
rial will adhere to all parts of the nasal cavities. Bleeding from 
the nose may occur, and it is usually due to the attempt of the 
patient to remove these incrustations. There is a constant desire 
to free the nostril. A sensation of accumulated material in the 
postnasal cavity is often present, largely due to reflected irritation 
owing to the accumulated secretion in the nose. In the variety 
associated with infection, the secretion is profuse, mucopurulent, 
and irritating, and the odor is marked. The tendency to " slug " 
formation is irregular, and it may even block the entire nostril, 
or may form as a hollow cast of the nostril. This variety usually 
involves both the nasal cavity and nasopharynx, owing to the dis- 
charge of the irritating secretion over the mucous membrane of 
these structures. If associated with any sinus lesion, especially 
that of the sphenoidal sinus, the odor is most marked, and will be 
found to as great an extent as before, even after the removal of all 
the fetid material from the surface. 

The symptoms, while tolerably constant, vary much in inten- 
sity with the stage and severity of the morbid process, and in some 
cases may be so mild as not even to direct attention to the nose as 
the seat of the trouble. They are always gradual in development. 
Perhaps the most obvious is the horrible odor from the nostrils, 
worse usually in the morning, which, itself indescribable, leaves 
in the memory of the practitioner who encounters it a lasting and 
valuable diagnostic point. Usually the patient believes it to be 



ATROPHIC RHINITIS. 133 

from gastric trouble or a decayed tooth, and consults a general 
practitioner or the dentist rather than the specialist. In a large 
proportion of cases both of these conditions will be found present, 
and because of their occurrence will frequently mislead the physi- 
cian from the true site of the lesion. Whether this odor is due 
to free fatty acids liberated in a fatty fermentation, to the product 
of a specific germ, or to saprophytic infection of the nasal secre- 
tion is as yet an undecided question. Fortunately the odor, 
penetrating and constant as it usually is, if untreated is perceived 
slightly or not at all by the patient, owing to his partial or com- 
plete loss of smell. There are dryness and irritation in the nostril 
and nasopharynx, and an absence of secretion is complained of. 
An itching in the anterior region of the nasal walls and septum 
and the vestibules is not uncommon. There is a sense as of a 
foreign body in the nose, and attempts to dislodge it are made by 
picking the nose, by exerting traction on the alae to stretch the 
membrane, and by violent blowing of the nose or hawking into 
the nasopharynx. With these efforts there is usually loosened more 
or less of the secretion encrusting the nasal walls, or loosening may 
occur without effort of the patient, and lumps or small masses of 
it are expelled either through the anterior nares or through the 
choanse into the pharynx, and thence expectorated. These vary 
in size, shape, and character. They may be small lumps or 
large, flat, irregular plates or large sheets ; they may even form 
more or less perfect moulds of the surfaces from which they are 
detached. They may be of a putty-like consistency, or tough, 
leathery, dry, and hard, vary in color from a grayish-green to black, 
and stink frightfully. If the disease be mild or in its incipiency, 
the discharge may be soft, and but little thicker or firmer than 
partially inspissated pus. The crusts may in some cases cause 
a temporary stoppage of nasal respiration by blocking the choanae ; 
and cases in which the crusts blocking both posterior orifices have 
been connected by an intervening band, formirig an expectorated 
structure not unlike a pair of spectacles in shape, have been 
reported. There is but little pain, none, as a rule, except of a dull, 
heavy character over the bridge of the nose or back of the orbits, 
and possibly a slight dull headache. Incapacity for mental activ- 
ity and hebetude are often present, and the patient may be de- 
pressed or even become melancholy from brooding over the social 
ostracism which the disgusting odor of his malady enjoins. Hoarse- 
ness is not infrequent, and a peculiar hacking cough is often pres- 
ent. Dyspeptic symptoms are very common, and the general con- 
dition loses tone, both from the impaired nutrition resulting from 
the gastric catarrh produced by swallowing parts of the secretion 
or germs detrimental to digestion and from the inhalation of air 
loaded with noxious products. Epistaxis is not infrequently brought 



134 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

on in a mild form by picking the nose. The sense of smell is im- 
paired or lost, taste is correspondingly vitiated, and the aural func- 
tions interfered with. In well-marked typical cases a peculiar 
facies develops, with widely expanded nostrils, the plane of which 
is less horizontal and more vertical than normal, forming a so- 
called " snub-nose " — the alse thin and flat, and the sulci separating 
them from the cheeks lessened or obliterated. Some cases have the 
strumous appearance, dull, expressionless face, thick lips, enlarged 
glands, and acne or various reflex rashes, while others show no 
characteristic facies. On inspection the greatly enlarged nasal 
space is evident. The postnasal space and the roofs of the fossa 
may often be seen from the anterior nares. 

The membrane of the turbinated bodies, especially the inferior, 
is greatly reduced in size, making the contour sharper and 
better defined. The meatuses are usually patent, and the area 
of the membrane visible by anterior inspection is greatly en- 
larged. The lining membrane is shrivelled and shrunken, dry, 
glazed, and of a pale color, and has lost the original soft, velvety feel 
to the touch of the probe, offering instead a hard, resistant surface 
which does not dent on pressure. A varying amount of inspissated 
secretion is present as stringy threads crossing the cavities, or 
masses impacted in the olfactory slits or meatuses, or in the shape 
of dark, ill-smelling crusts, which require some force in removal, 
and usually, when removed, leave a slightly abraded surface, with 
a little oozing of blood. Indeed, the crusts may be so extensive as 
to cover the membrane, requiring their removal before the latter 
can be brought into view. When such cleansing is necessary, the 
membrane is temporarily darker in hue, but soon returns to its 
characteristic pale condition. Slight abrasions or superficial des- 
quamations, marking the site of detached crusts or the result of 
the patient's meddlesome fingers, may be present, but true distinct 
ulceration is uncommon. The membrane of the nasopharynx presents 
largely the same characteristics, and an atrophied condition, more 
or less complete, of the pharyngeal tonsil is not rare. We have 
tried to portray the symptoms of a well-developed typical bilateral 
case, but it must be carefully borne in mind that variations are 
extremely common, not in the essential features, but in the loca- 
tion and severity of the process. It may be unilateral, small areas 
may be implicated, simple chronic conditions, acute exacerbations 
of coryza, or normal conditions coexist in the same or the adjoin- 
ing passage and correspondingly mask the symptoms. 

The nasal cavities are not obstructed owing to any excess of 
tissue, but still they may not present the wide-open appearance 
seen in the simple atrophic variety. 

In advanced cases, owing to the change in the nasal submucosa, 
there may be an alteration of the contour of the nose involving 



ATROPHIC RHINITIS. 135 

especially the vestibule, which in turn alters the labionasal folds, 
thereby changing the facial expression. 

There is often alteration in the voice late in the disease owing 
to the alteration in the nasopharynx and nostrils increasing the 
space and changing nasal resonance. 

In advanced cases there may be alteration in the sense of hear- 
ing. The eyes are injected and watery, and the physiognomy is 
altered, giving a dull, listless expression. 

Diagnosis. — The diagnosis of the variety due to contraction 
owing to pre-existing inflammatory processes can be differentiated 
by inspection and probe-palpation and on the appearance of the 
secretion. 

Prognosis. — The prognosis in the variety due to contraction 
is fairly good as to the relief of the patient from the most dis- 
agreeable of the symptoms — namely, the odor. As to the perma- 
nent restoration of the tissue, the prognosis is bad. The outlook 
in those cases due to an infectious process is bad, especially when 
due to, or associated with, a sinus lesion. 

Complications. — The nasopharynx is frequently involved, 
and there is a tendency to accumulation of the tenacious material 
in the vault of the pharynx, while the Eustachian tubes are likely 
to be implicated through the spreading of inflammation by con- 
tinuity of structure. The accessory cavities, if not involved 
primarily, are likely to become so secondarily. Various reflex 
conditions and nervous complications, such as neuralgia, giddi- 
ness, and paresthesia, may occur. 

Treatment. — When not due to infection, the main object of 
treatment is to relieve the patient of the disagreeable odor. If 
any irregularities of the nasal orifice exist and any obstruction be 
present, they should be removed. To clear the nostril of the ac- 
cumulated material and to prevent its accumulation, persistent and 
thorough cleansing is required. For this purpose there should be 
used first a douche of water at a temperature as hot as can be borne 
by the patient. This may be rendered slightly alkaline by the 
addition of 8 grains of biborate of soda to the ounce. This 
process should be followed by the use of equal parts of hydrogen 
peroxid (15 volume), aqueous extract of hamamelis, and cinnamon 
water. The patient should then be instructed to clear the nostril 
as much as possible by blowing the nose. This, then, should be 
followed by a warm alkaline douche consisting of — 

1^. Sodii biboratis, 
Sodii bicarbonatis, 
Sodii chloratis, 

Potassii bicarbonatis, da gr. xv (.9) ; 

Acidi carbolici, gtt. iij (.18) ; 

Aqua? destillatae, flsij (60). 



136 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

I believe, if faithfully persisted in, this course of treatment 
will free the nostril and, in the majority of cases, relieve the patient 
of the disagreeable odor. After clearing the nostril thoroughly, 
the patient should be instructed to apply to each nostril, by means 
of an ordinary medicine-dropper, from 4 to 6 drops of refined 
carbon oil, to which has been added 1 grain of iodin to the 
ounce ; or excellent results may be obtained by using instead the 
simple coal oil or lamp oil, dropping it in each nostril as described 
above. Where the slugs are difficult of removal, pledgets of cot- 
ton saturated with coal oil, left in the nostril from five to twenty 
minutes, will usually afford relief, if persisted in. The above 
plan of treatment can be safely entrusted to the patient. Better 
results, however, can be obtained if the physician sees the patient 
regularly and attends to the cleansing process himself. It is a 
good plan to dry the membrane carefully by means of pledgets of 
cotton, after cleansing as described, before applying the medicinal 
agent. Where the surface is infected and the discharge purulent^ 
after the use of the cleansing solution it may be necessary to get 
rid of the infection on the surface by means of an astringent. I 
have had good results from the use of a 3 per cent, chlorid-of- 
zinc or a 1 : 2000 trichloracetic-acid solution ; or, if the process 
be ulcerative and infection be marked, Loffler's solution should 
be applied. A weak solution of formaldehyd with glycerin, the 
glycoformalin solution, is an excellent cleansing agent. 

Beneficial stimulating results can be obtained by insufflation, 
after thorough cleansing of the membrane, of a powder of stearate 
of zinc, to which is added 5 to 20 grains of powdered nitrate of 
silver. This should not be applied oftener than every third day. 
Equally stimulating effects may be obtained by the use of formal- 
dehyd solution, 1 : 500. 

The administration of lactic-acid bacteria has been irregularly 
beneficial, and sufficient data has not been obtained to give definite 
results. However, certainly in some instances it is beneficial. 
Goodale has treated a series of cases by cultures of bacteria gen- 
erating lactic acid. These cases included conditions of atrophic 
rhinitis with ozena and chronic suppuration of the various sinuses. 
The preparation was sent twice a week from the laboratory in two- 
ounce bottles, and a sufficient quantity was given the patient to use 
in an atomizer. Fresh material was given them every week, with 
instructions to keep it in a cool place and to observe aseptic pre- 
cautions so far as possible in handling it. The patients were told 
to cleanse the atomizer with alcohol before introducing the culture 
fluid, and in the case of atrophic rhinitis, with crust formations, 
to remove the crusts as completely as possible before employing 
the spray. Goodale is of the opinion that a distinct effect has 
been produced by the culture in some cases of ozena, characterized 
by general crust formation. The results appear to be comparable 



ATROPHIC RHINITIS. 137 

to those produced by argyrol. It remains to be seen, however, 
whether more than a temporary effect is produced. In localized 
chronic suppurative sinusitis, attended by hypertrophy and polyp 
formation, no effect could be detected. 

Ulceration, fortunately, is rare, and the bleeding which fre- 
quently occurs is more often the result of undue roughness in the 
removal of the crusts. Should there be involvement of the sinuses, 
it should be treated as given under lesions of the sinuses. The 
internal administration of the so-called tonic alteratives certainly 
produce excellent results in certain varieties of atrophic cases. 
The various arsenical preparations, such as Fowler's or Dono- 
van's solution, and the compound wine of iodin, are not only 
excellent systemic tonics, but also have a selective action on the 
mucous membrane. 

The iodids, especially the iodids of soda and potassium, 
which have selective action on the glandular secretions, will 
often produce excellent results. The patient should take plenty 
of outdoor exercise, and all the functions should be kept particu- 
larly active. 

Atrophy Secondary to a Lesion Elsewhere, or which is 
a Local Manifestation of a Constitutional Lesion. 

By this variety of atrophic rhinitis is meant that patholog- 
ical alteration which is brought about by cyanotic congestion, 
and is analogous to the condition seen in red atrophy of the 
liver. 

Etiology. — The condition may or may not be associated with 
irregularities in the nasal cavities, but the primary cause is an 
alteration of some structure, such as the lung, liver, kidney, or 
heart, by which there is damming back of the venous circula- 
tion, causing venous stasis, most likely to occur in lax struct- 
ures, and especially marked in the mucous membrane. Besides 
the element of engorgement, there is another factor which must be 
considered. Any lesion affecting the intestinal tract, the lungs, 
the liver, or the kidney, in fact any of the excretory and. secretory 
organs, will necessarily prevent the elimination from the system 
of material for which the economy has no further use. This irri- 
tating material floating in the blood acts as an irritant and tends 
to cause slight inflammatory reaction. I do not believe that ex- 
ternal local irritation ever brings about this same cyanotic con- 
dition. 

Pathology. — The submucosa of the mucous membrane, which 
contains the blood-vessels, lymphatics, nerves, and mucous glands, 
is the first to suffer from the involvement. There may be slight 
inflammatory action in the early stage of the cyanotic congestion, 



138 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

as well as an increase in the connective tissue of the submucosa, 
which, however, will only be slight. For, although the tissue is 
full of blood, it is in no sense an element of nutrition, and, as 
organization demands good nutrition, that process is early arrested. 
The overdistended vessels, then, by their pressure produce atrophy 
of the perivascular structure, and in addition to atrophy from press- 
ure there is also atrophy from lessened nutrition. (See Fig. 60.) 
The surface-epithelium will undergo nutritive changes — atrophy 
and degeneration. While the appearance of such a tissue on inspec- 
tion does not present the shrunken membrane typical of atrophic 
rhinitis, as usually described, yet the process is distinctly one of 
atrophy in every sense of the word. For atrophy means lessened 
nutrition and lessened work and function, but not necessarily les- 
sened size; the enlargement of the structure is only apparent, 
being due to the fluid-distention, while the structural elements 
are reduced in amount. The early stage of this variety is identical 
with cyanotic rhinitis. 

Symptoms. — -The mucous membrane involving the middle, 
the inferior, and sometimes the superior turbinates, as well as 
the membrane lining the septum, will be boggy, tense, and in- 
jected, with the associated phenomena of acute inflammation. There 
is usually some redness of the nose externally. There is marked 
nasal obstruction owing to the swelling, and, until late in the dis- 
ease, there is, as a rule, profuse secretion, or rather exudation, 
which is largely due to the overdistended paretic vessels. The 
voice has a peculiar nasal twang, owing to the lack of nasal reso- 
nance. Frontal headache and sense of fulness over the bridge of 
the nose are present. The eyes may be watery and injected. 
There is loss of the sense of smell, owing to the involvement of the 
peripheral-nerve filaments. In this variety there may be very 
little odor. Very much the same condition will be present in the 
nasopharynx and even in the larynx. The severity of the symp- 
toms is largely controlled and dominated by the systemic lesion 
responsible for the nasal manifestations. There is a condition 
presented in plethoric individuals which gives symptoms closely 
resembling those just described, except that the engorgement is a 
hyperemia instead of a passive congestion, and is in reality a 
plethoric rhinitis. 

Prognosis. — The prognosis will depend entirely on the loca- 
tion of the etiological factor and whether it be a condition ame- 
nable to treatment. I have observed cases having symptoms 
identical with those described above, which were due to organic 
lesion of the mitral valve of the heart. In such cases the treat- 
ment would only be palliative. 

Diagnosis. — The diagnosis must be made between intumes- 
cent rhinitis and simple acute rhinitis, and, possibly, in certain 



PURULENT RHINITIS. 139 

stages of simple chronic rhinitis. This can be done by inspection, 
probe-palpation, and by the history and clinical phenomena. 

Complications. — There may be involvement of the accessory 
sinuses, though this is the exception. Ulceration may take place, 
closely resembling varicose ulceration, and is attended with con- 
siderable bleeding. Involvement of the Eustachian tube may 
take place if there be the same condition present in the naso- 
pharynx. The lacrimal duct may be involved, or there may be 
neuralgia of the nasal nerve. 

Treatment. — The treatment should be directed toward the 
constitutional condition, which is the underlying factor. This 
must be determined by a careful clinical examination of the indi- 
vidual. For the relief of the nasal obstruction I know of nothing 
better than depletion, and this can be accomplished by linear inci- 
sion, a procedure which should not be resorted to until it is demon- 
strated that the underlying cause producing the cyanotic congestion 
is an incurable one. Then the treatment for the nasal condition 
must be directed toward affording the patient relief from the ob- 
struction. Local depletion can be obtained by the insertion into 
the nostril of a pledget of cotton saturated with a 20 to 40 
per cent, solution of ichthyol. This will afford only temporary 
relief, and should be used in association with the administration 
of remedial agents for the relief of the underlying cause. 

Atrophy Due to Trophic Lesions. 

A simple atrophic process involving the nasal mucosa, not asso- 
ciated with any inflammatory phenomena, I believe theoretically 
to take place, as it unquestionably occurs in other tissues. I do 
believe, however, that when occurring in the nasal mucosa it is 
associated with some systemic condition or some idiosyncrasy on 
the part of the individual, which may be scrofulous or tuberculous. 
Should it be due to a simple atrophy, the symptoms and treatment 
would be the same as in any other variety of atrophic rhinitis. 
Regardless of variety or type, the local- or terminal-nerve fila- 
ments are involved in the atrophic and degenerative processes and 
their functional activity altered in accordance with the progress of 
the pathological alteration in the structure. 

The trophic variety, or trophoneuroses which are due to cen- 
tral- or peripheral-nerve lesions, would not differ in the pathology 
or treatment. 

PURULENT RHINITIS. 

Definition. — Purulent rhinitis is an exceptionally rare condi- 
tion in which the nasal mucous membrane becomes infected and 
practically becomes pus-secreting or -manufacturing. This does 



140 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

not include cases in which infection follows injury or the lodge- 
ment of foreign bodies in the nose. The condition is usually 
chronic. 

Synonym. — Purulent nasal catarrh. 

Etiology. — This variety of rhinitis must not be confused with 
strumous rhinitis. There is much difference of opinion as to the 
cause in adults, but that such cases do occur there is no doubt. 
I have seen two cases in which there was a history of infection 
on the part of the patient by picking the nostrils after having the 
fingers in contact with an infected discharge, in one case from 
the urethra (non-specific), and in the other from the ear. Under 
favorable conditions I believe it possible for such infection to 
occur. 

In the New-born. — Infection of the nasal mucosa of the new- 
born is generally believed to take place during labor and to be the 
result of careless or insufficient cleansing after birth. It must, 
however, be remembered that a violent inflammation of the deli- 
cate mucous membrane in the infant may be set up by exposure to 
irritating material in the air, or by the entrance of irritating sub- 
stances when washing the child ; yet it would seem that there are 
cases in which there is a purulent discharge not dependent on any 
infection from the vaginal passages of the mother — local in char- 
acter and dependent upon constitutional conditions. The infec- 
tion is probably mixed rather than due to any one special germ. 

Pathology. — The irritation, produced by the poisons gen- 
erated by the bacteria, causes on the inflamed surface a condition 
practically the same as that found in the wall of an abscess. The 
proliferating cells — really granulations or, more strictly speaking, 
embryonic cells — are attacked by the bacteria and their products, 
and a process of liquefaction-necrosis takes place ; the mucous 
membrane, following the infection and inflammation, practically 
becomes pyogenic. This is fairly well proven by the fact that 
after recovery the membrane rarely returns to the normal. This 
mode of production does not apply to the so-called chronic variety, 
which is, in reality, strumous rhinitis. 

Symptoms. — In purulent rhinitis there is a constant dis- 
charge, usually from both nostrils, of a thick tenacious mucopuru- 
lent material, the color of which varies, but is generally bright 
yellow. The attack is often ushered in by slight febrile symptoms. 
The discharge is irritating, and often produces excoriation and 
ulceration of the upper lip. The area of infection is limited to 
the anterior nasal cavities. There is slight, if any, obstruction to 
nasal breathing. The discharge is usually through the anterior 
nares, but in severe cases may be through the nasopharynx. A 
slight odor is noticeable, which is increased if the discharge be- 
comes less fluid and tends to remain within the nostril. 



NASAL HYDRORRHEA. 141 

Prognosis. — Recovery may take place, but the mucous mem- 
brane will never entirely recover its function. 

Treatment. — The parts should be first cleansed with hydro- 
gen peroxid (15 volume), followed by a cleansing alkaline, antisep- 
tic solution, such as : 

!ty. Sodii biboratis, 

Sodii bicarbonatis, da gr. x (.6) ; 

vel Acidi carbolici, gtt. iij (.18); 

Listeria, 3ij (7.5) ; 

Aquse cinnamomi, 3iv (15.) ; 

Aquae, q. s. ad flsj (30.) ; 

which is best applied by means of the ordinary straight-tube atom- 
izer (Fig. 32), or by means of the cotton swab. The application 
should be repeated every three or four hours daily. After cleans- 
ing the membrane carefully, dry it by means of cotton pledgets, 
and apply an astringent. The best results will be obtained by 
using the astringent in solution, controlling its strength by the 
severity and gravity of the case. Twenty grains of sulphocarbo- 
late of zinc to the ounce of water is one of the best. If bichlorid 
of mercury be added to any solution, the strength should not be 
over 1 : 8000 or 1 : 10,000. Any of the simple astringents, such 
as glycerole of tannin, sulphate of copper, or alum, may be used 
as indicated. Permanganate of potassium, 5 grains to the ounce, 
while having little astringent property, will control the odor. 
After carefully cleansing and drying the surface, good results may 
be obtained by painting with a 50 per cent, solution of ichthyol. 
The general condition of the patient should determine the internal 
medication. Should there be any glandular involvement, the 
double sulphid of arsenic will give the best results in -^ to -^ 
grain doses three times daily after meals. 

The treatment of the disease in children should consist in 
keeping the nostrils open by the use of equal parts of lime water 
and skimmed milk, in the manner described under Treatment of 
Acute Coryza in Children (page 92). Inunctions of cod-liver oil 
and the syrup of the iodid of iron are to be given to enable the 
general economy to come to the aid of the diseased area. 

NASAL HYDRORRHEA. 

Definition. — A rare and obscure nasal manifestation, character- 
ized by a profuse discharge of a thin, watery fluid from the anterior 
nares. 

Synonyms. — Hydrorrhcea nasalis ; Rhinorrhea. 

Etiology. — The etiology is very obscure. In all, the author 
has been able to collect but 27 well-authenticated cases, in 



142 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

each of which the apparent etiological factors differ in degree or 
kind from those of the others. Thus, trauma is cited with gradual 
and persistent escape of cerebrospinal fluid. This, however, was 
not a true case of nasal hydrorrhea. Polypoid growths and 
chronic catarrh of the antrum are variously regarded as cause 
or result. It occurs as a reflex neurosis, following involvement 
of the trifacial nerve, or in the same manner subsequent to caries 
of the teeth, cerebral lesions, or intracranial disorders, usually of 
the optic tract. The majority of the cases, however, seem to be 
the local expression of some constitutional condition, especially 
those in which venous return is impeded, producing a cyanotic 
state of the nasal membrane, allowing an escape of serum into the 
perivascular tissue, causing a distention or edema, which is finally 
relieved by a free discharge. This is especially true in systemic con- 
ditions due to renal, hepatic, cardiac, or intestinal involvement, some- 
times following epidemic influenza. It may be associated with lithe- 
mic, rheumatic, or gouty conditions. A case occurring in the author's 
practice and reported by him was undoubtedly due to such a con- 
gestion dependent upon a condition of chronic malarial poisoning. 

Pathology. — But little can be definitely said as to the pathol- 
ogy. In the case of the author's already mentioned, the mucous 
membrane during the attack was swollen, edematous, and boggy, 
in color a dull bluish-red or pale pink, resembling more a chronic 
congestion than an acute hyperemia. This was further borne out 
by the slow obliteration of indentations made by probe-pressure. 
Microscopic examination of a bit of removed tissue snowed a 
small round-celled infiltration into the submucosa, a relaxed and 
thinned condition of the vessel- walls, and some connective-tissue 
pigmentation. The epithelial layer had evidently been the seat of 
severe desquamation, and many of the cells were in the stages of 
cloudy swelling and granular and hydropic change. The histolog- 
ical structure shows that the process is somewhat similar to that 
observed in red atrophy of the liver, in which the intravascular 
pressure produces, by lessening nutrition, atrophy and surface- 
desquamation of the dependent structures. 

Chemical analysis of the fluid shows nothing characteristic, ex- 
cept that the inorganic salts predominate. This, however, is true in 
any inflammatory process of mucous membrane. Bacteriological 
examination reveals nothing of special interest. 

Symptoms. — The chief symptoms relate directly to the char- 
acter and duration of the discharge. During the seizure this mani- 
fests itself as a constant dropping from the nostrils of a clear, 
transparent, colorless, watery fluid, either coming on suddenly or 
gradually, and lasting for a variable time. Usually the attacks 
begin with sneezing and a moderately severe headache, and show 
a certain periodicity, one or more occurring each day, or the con- 



NASAL HYDRORRHEA. 143 

dition becoming almost or quite continuous during the twenty-four 
hours. In many cases the disease runs a course marked by re- 
missions which are from a few days to several weeks in duration. 
The amount of fluid discharged is variable. 

During the discharge there may be considerable pain from in- 
volvement of the trifacial nerve, or this feature may be lacking. 
The fluid may be irritating or bland, though in the advanced state 
of the condition, owing to blunted nerve-sense, the chief annoy- 
ance is not from the character of the fluid, but its continued 
presence. If the attack occur at night, the nasal cavities may fill 
and overflow, soiling the bed-linen ; usually, however, the dis- 
charge is lessened during this period. Cough or spasm of the 
glottis may occur from irritation, the discharge escaping through 
the posterior nares, and sneezing may be so excessive as to cause 
annoyance. The constitutional symptoms vary, but should be 
carefully taken into consideration in each case. 

Diagnosis. — The constant and abundant clear discharge ; 
the history given by the patient ; the obstinate resistance to treat- 
ment, coupled with inspection and probe-palpation of the mem- 
brane and a careful search for some constitutional disorder, should 
prevent an error in diagnosis. 

Prognosis. — The prognosis depends almost entirely upon the 
ability of the practitioner to identify correctly and to remedy the 
underlying condition. A spontaneous cessation of the disease may 
very rarely occur. 

Complications. — Complications are not common. Chief, 
perhaps, is the occurrence of polypi. Constitutional conditions 
should receive thorough examination as to their possible causative 
relationship before being classed as complications. 

Treatment. — Success in the treatment of nasal hydrorrhea 
depends on discovering the underlying cause of the condition. By 
careful eliminative study the true etiological factor is to be obtained 
and the appropriate treatment applied. Locally, during the attack, 
such solutions as — 

1^. Olei myrti, 

Olei santali ad gtt. v (.3) ; 

Alboleni (liquid), flsj (30.).— M. 

Ify. Camphorse, gr.j(.06); 

Menthol, gr. iv (.24) ; 

Benzoinol, fig (30.) ; 

will lessen materially the irritation produced by the secretion. A 
3 per cent, solution of chlorid of zinc applied twice daily will in a 
measure control the secretion in some cases. Adrenalin chlorid 



144 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

has been recommended in this condition, but in my experience has 
been very unsatisfactory in its results. 

CHRONIC EDEMATOUS RHINITIS (CYANOTIC RHINITIS). 

Definition. — Edematous rhinitis is an affection of the nasal 
mucous membrane, characterized by a watery infiltration into the 
connective tissue, most marked in the inferior and middle tur- 
binated bodies. It may be acute or chronic. 

Synonym. — Rhinitis cedematosa chronica. 

Etiology. — There is hepatic involvement in the history of the 
majority of cases, and there is a probability of its being of biliary 
origin. Pathological conditions of the liver, kidney, heart, and 
lungs, interfering with the venous and arterial circulation, thus 
producing cyanotic congestion in tissues remote to the organ, are 
the most likely cause of the edema. The condition may occur 
very rarely in connection with asthma. It has been regarded by 
some as a neurosis. No specific cause is known. The condition 
is closely allied to intumescent and the second variety of atrophic 
rhinitis, but does not tend toward secondary changes. 

Pathology. — There is swelling of the turbinated bodies, due to 
an infiltration of serum into the connective tissue. In some cases 
the swelling is migratory in character, and in one reported case 
there was a surface-flow of thin serum. It may be general or 
local. The vascular structures, both arterial and venous, are 
engorged or passively congested, causing obstruction, the increase 
in bulk being due to the vascular engorgement and not to tissue- 
proliferation. 

Symptoms. — There is swelling of the middle and inferior 
turbinates, which may be intermittent or constant, with a cor- 
responding degree of interference in nasal respiration. This swell- 
ing may change its location, its constancy depending entirely on 
the underlying organic etiological factor. The condition may re- 
semble a cyst, and gives rise to pain, lacrimation, and a dis- 
charge of thin serum. On puncture with a bistoury a thin serum 
exudes. Cocain has little or no contractile power upon the en- 
largement. In the late stage there may be ulceration. 

Diagnosis. — Rests upon the symptoms given. 

Prognosis. — Depends entirely on the ability to relieve the 
underlying exciting cause. 

Treatment. — Scarification is the only local treatment advised ; 
attention should be given to correcting any existing malforma- 
tion of the nose. Constitutional treatment varies with each case. 
Special attention should be given the condition of the aliment- 
ary tract. 



NASAL SYPHILIS. 145 

SPECIFIC INFLAMMATIONS (GRANULOMATA). 

1. Syphilis. 

a. Acquired. 

b. Congenital (hereditary). 

2. Tuberculosis. 

Lupus. 

3. Glanders. 

4. Leprosy. 

5. Actinomycosis. 

6. Khinoscleroma. 

NASAL SYPHILIS. 

Synonyms. — Specific catarrh ; Specific rhinitis ; Syphilitic 
ozena ; Syphilitic rhinitis. 

Definition. — A specific infectious chronic inflammatory dis- 
ease of the nasal passages, occurring as the local exhibition of a 
general systemic morbid condition. It is believed to be due to a 
specific germ, as yet unproven, and in relation to its establish- 
ment is described as being congenital or acquired. The acquired 
form is characterized by a chronic course, consisting of a series of 
three clinical stages, which are marked by characteristic morbid 
phenomena and usually separated by quiescent periods. The 
stages are known as the primary, or the stage of initial lesion ; the 
secondary, or the stage of cutaneous and mucous-membrane erup- 
tions ; and the tertiary, or the stage of gum ma-formation, of altera- 
tion and, finally, of obliteration of the connected vascular supply, 
with subsequent extensive tissue-necroses. The congenital form 
occurs in infancy and youth, and its initial stage is passed in utero. 

In the above definition and in the following description are 
included for consideration only those manifestations localized in 
the nasal passages and such of the systemic exhibitions as may be 
necessary in diagnosis. 

The disease, occurring in all walks of life from infancy to old 
age, modified by so many conditions, now following a typical 
course and again apparently omitting certain stages and modifying 
or overlapping others, presents a complexity of morbid manifesta- 
tions as varied in its nasal display as elsewhere. We shall con- 
sider the disease in its acquired and hereditary forms, and shall 
describe the former in its primary, secondary, and tertiary stages, 
and the latter in its early and late manifestations. 

Acquieed Syphilis. 

Definition. — That form of syphilis in which the inoculation 
of the disease occurs during, or, as in the vast majority of cases, 
after birth. By far the greater number of cases occur after puberty. 

Etiology. — The specific organism of this disease has been es- 
tablished beyond a doubt, this organism generally being accepted 

10 



146 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

as the Spirochseta pallida, as described by Schaudinn and Hoffmann 
in 1905. The insusceptibility of the lower animals to the dis- 
ease has so far baffled proof that this germ is the causative 
agent, and some authors claim it is identical with certain other 
organisms without pathogenic properties. The disease is ac- 
quired only by inoculation with the specific principle through 
some abrasion or wound of an exposed surface, and this usually 
occurs during impure sexual congress. It may be contracted by 
kissing, by the use of infected household implements, following the 
employment of infected surgical instruments, and has been con- 
veyed in vaccination and tattooing. It may follow common use of 
an infected pipe, or the circulation of the factory-hands' beer-kettle. 
In comparatively few cases has the initial lesion had its site in the 
nasal passages. In the majority of these the inoculation has taken 
place through the medium of an infected finger. In others infected 
instruments, such as an Eustachian catheter, have been the interme- 
diate agents, and a few cases have followed contact with discharge 
from a mucous patch upon the tongue or lip of a person suffering 
from the disease. Direct contact of the sexual organs in filthy prac- 
tices has been the history in a few instances. The greater number 
of cases of nasal syphilis begin and pursue their course as part of 
secondary or tertiary lesions following a primary sore elsewhere, 
and are usually of commensurate severity. The strumous diathe- 
sis and a weakened bodily resistance seem to have a predisposing 
effect in localizing the manifestation and influencing its gravity. 
Sex, age, occupation, temperament offer no protection and, with 
the exception of the laws of immunity as formulated by Colles and 
Profeta — viz., that in the tertiary form there is no contagion, 
there seems to be no protection against it. The disease, however, 
with the advance of civilization and the better understanding 
and treatment of modern times, seems to be not so severe as 
formerly. 

Pathology. — Primary Stage. — The initial lesion of syphilis 
shows in the nasal passages the essential features that it displays 
elsewhere. After an interval varying from ten days to six weeks 
from infection, there appears at the site of inoculation a papule 
which is comparatively small, hard, usually round, elevated, dis- 
tinctly marginate and reddish or grayish-red in hue. This usually 
enlarges and soon undergoes central necrosis from without inward, 
and an ulcer forms, which has a fairly smooth floor and sides, not 
rough and shaggy, as is the tubercular ulcer, and not very deep. 
It is covered by a thin glairy secretion. The morbid histology of 
the growth shows it to consist of an abundant inflammatory infil- 
trate of small round cells into the mucosa and upper part of the 
submucosa. The vessel-walls are also infiltrated and show begin- 
ning sclerotic change. There are numbers of epithelioid cells, and 
some giant cells, and the bacilli already described are usually pres- 



NASAL SYPHILIS. 147 

ent. A later section will show the degenerative changes that fol- 
low pressure of the infiltrated cells and obliterated nutritive sup- 
ply. The epithelial covering is gone, and the masses of cells have 
undergone, or are undergoing, liquefaction-necrosis and discharge, 
or, in the deeper parts, absorption. The inflammatory infiltrate 
in the immediately adjacent areas, which still possesses sufficient 
nutriment, is in process of organization and formation of cicatri- 
cial tissue. Sections of the adjacent lymph-glands at this time will 
show an enlargement due to masses of proliferated cells, which 
are more or less completely undergoing resolution. 

Secondary Stage. — The pathology of the coryza of this stage 
is essentially that of a simple catarrhal inflammation. There are 
the same vascular phenomena. The vessels are distended and 
engorged with blood, paresis and leakage of the liquor sanguinis 
follow, with a corresponding diapedesis and escape of white and 
red cells. The connective-tissue spaces are distended by the exu- 
date, and the membrane macroscopically is red and swollen. As 
the amount of interstitial infiltrate increases, there is an escape of 
the fluid through the basement membrane, which, at first clear, 
gradually becomes thicker by admixture with corpuscular ele- 
ments. The epithelium undergoes degenerative change from per- 
verted nutrition, and is desquamated. Usually this stage is more 
protracted, and is followed by resolution. The vascular tonus is 
regained, the infiltrate is absorbed, the epithelium is replaced, and 
the membrane practically shows no evidence of its catarrhal con- 
dition. The mucous patch presents itself to the eye as a small 
papule, with either an oval or a rounded outline, slightly elevated 
above the surrounding tissue and of a bluish-red color. They 
vary in size, and not infrequently several small papules coalesce 
into a larger mass. Ulceration does not occur in every case, but, 
as a rule, soon folloAvs, and the lesion becomes practically an ulcer 
which is comparatively shallow, has slightly raised edges, is sur- 
rounded by an areola of a darkish-red hue, and is covered by a 
grayish or yellowish creamy pus. This pus can be easily removed 
by a spray, and, when so removed, a surface is left which, though 
raw-looking, bleeds but slightly if at all. After a variable period 
healing takes place, and if the process has been, as it usually is, 
superficial, little or no evidence of its occurrence may remain. If, 
however, it has extended somewhat deeply, there is formed a 
dense glistening cicatrix. The morbid histology shows at first an 
abundant infiltrate of fluid and of small round cells into the 
mucosa and external zone of the submucosa. The epithelial cells 
are swollen and turgid, and within and between them is an abun- 
dance of fluid and small round cells. There is, however, little or 
no evidence of organization or vascularization, and the cellular 
elements seem to acquire a somewhat gelatinous character. An 
examination at a later stage shows the epithelium to be desqua- 



148 DISEASES OF THE ANTERIOR NASAL CA VITIES. 

mated, and fatty degeneration, disintegration, and liquefaction of 
the infiltrated and proliferating cellular elements to be taking 
place, forming an ulcer of variable depth. The epithelium at the 
margin shows a tendency to extend inward by proliferation, and 
the surrounding tissue exhibits an inflammatory condition. There 
is little or no evidence of any tendency to organize, and the blood- 
vessels show no budding. At a still later stage the nutritive bal- 
ance is recovered, and the microscope reveals the process of heal- 
ing by proliferation of the cells and recoating of epithelium, or, if 
the ulcer extends deeper, by the organization of new tissue and 
formation of a fibrous cicatrix. 

Tertiary Period. — The lesions of this period are severe and 
extensive, involving both the bony or cartilaginous framework and 
the overlying mucous structures. In the mucous membrane the 
submucosa is primarily affected, and there is a development of 
gummatous nodules or a diffuse inflammatory process of the same 
type. This gives rise to a diffuse thickening, or to local areas, 
varying in size, rounded in shape, slightly elevated, and hard, or 
soft as the process advances. If a section be made of the latter 
form, there will be seen macroscopically a homogeneous mass, 
traversed by trabecule of fibrous tissue, comparatively blood- 
less, with a pseudocapsule formed by fibrous development of 
the adjacent structure, with irregular fibrous bands radiating 
from it into the sound tissue. If unmodified by treatment, the 
gumma undergoes a central fatty degeneration, the overlying tissue 
necroses, and a deep, spreading, erosive, and foully discharging 
ulcer forms — the whole process, aside from specific influence, 
being consequent to the vascular implication of the disease. If, 
however, under proper treatment healing takes place, there results, 
owing to the trabecular running from the pseudocapsule to a sound 
anchorage, a peculiar stellate scar, which is pathognomonic of the 
disease. In its morbid histology the gummatous formation is seen 
to consist of masses of small round and epithelioid cells, and in the 
periphery giant cells. In a number of the cells also may be found 
the bacilli of Lustgarten, while, crossing through the cell-masses, 
at an early stage fibrous bands will be seen. The surrounding 
tissue exhibits an inflammatory proliferation, and considerable 
fibrous formation immediately adjacent to the tumor. The blood- 
vessels are early implicated and hyperplasia of the tissue takes 
place, which thickens the wall of the vessel. There is also a for- 
mation of new blood-channels by budding, but these new vessels 
soon are obliterated. Later, the center of the mass will be seen 
to have undergone fatty degeneration ; the overlying structures with 
lessened nutrition have undergone retrograde changes, and lique- 
faction-necrosis and infection have converted the whole into a deep 
and suppurating ulcer. Or if infection has not taken place, organi- 
zation of fibrous tissue in the site of the absorbed material is observed. 



NASAL SYPHILIS. 119 

Preceding, accompanying, or following the gummata, extensive 
and spreading necrotic changes take place in the bony and carti- 
laginous formations. Pathologically, these processes originate either 
in an inflammation in the superficies of the affected bone or as a 
gummatous development within it. In the former variety the 
lesion is similar to that of a simple ostitis, which may or may not 
undergo pyogenic infection. There are dilatation of the nutritive 
vessels, escape of blood-cells, and proliferation and, finally, organi- 
zation of embryonic tissue within the limits of the bony vascular 
canals. With this there is a fatty degeneration of the bone-cells, 
and these and the mineral salts of the bony structure are gradually 
absorbed. Asa result, the bone becomes progressively less firm in 
texture, and finally is nothing but a spongy honeycombed mass, 
with its interstices filled with granulation-tissue. If now no sec- 
ondary infection occur, the salts are completely removed, and a 
fibrous structure, exhibiting the inflammatory tendency to con- 
traction, results. If pyogenic organisms gain ingress, how T ever, 
the granulation-tissue undergoes liquefaction-necrosis. The newly 
proliferated cells undergo the same process as soon as formed, and 
the spongy and honeycombed bits of diseased bone are carried 
away as fast as detached in the ill-smelling purulent discharge. 
The intra-osseous gumma undergoes the same structural growth 
and changes that it exhibits elsewhere — gradually by its growth 
causing death and absorption of bone-substance and so forming a 
site for itself, and usually becoming surrounded by a thickened 
bony wall. As in the other variety of bone-involvement, caries 
may follow, with suppurative infection and discharge, or the mass 
growing, finally overreaches its nutriment, softens, and is absorbed, 
leaving a cavity or excavation which does not fill up. Cartilage 
undergoes essentially the same process. There are impairment of 
its circumferential blood-supply, lessened nutriment, softening, and 
absorption. 

Symptoms. — Primary. — The symptoms of the primary sore, 
when occurring in the nasal cavities, need but brief mention. The 
site may be any portion of the mucous area accessible to the 
infected finger or instrument, and in the majority of the reported 
cases has been the alse or septum. The chancre itself is painless ; 
but pain from its presence and continued pressure, usually of a 
neuralgic character, is not uncommon. The local symptoms do 
not differ from those of a simple, non-specific ulcerating papule at 
the same site. There is more or less occlusion of the nasal space, 
with proportionately affected respiration, phonation, and olfaction. 
Slight fever may attend its presence, and various reflex disorders 
may coexist. The papule is hard and firm to the probe, sharply 
circumscribed, and rapidly ulcerates. Its size may vary, and, 
when occurring on the anterior part of the septum, may com- 
pletely fill the vestibule and push aside the opposite ala. In- 



150 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

spection is often impossible because of the swelling. A very 
important symptom often present and occurring with the appear- 
ance of the chancre is the enlargement of the allied submaxillary 
lymphatic glands, forming the so-called indolent bubo. These 
enlargements are characterized by their distinctness, free move- 
ment, induration, slow growth, and comparatively small size. 
Furthermore, they are painless, do not usually suppurate, and are 
covered by normal integument. Local medication has no effect 
upon them, but specific treatment causes a prompt reaction. 

Secondary. — The secondary symptoms of nasal syphilis occur 
in a certain number of cases, and are but part of the constitutional 
exhibition of the specific virus, usually appearing within six 
months after the chancre, whether that occurs in the nasal mem- 
brane or elsewhere. The patient in a well-marked case at the 
onset of this stage generally believes he has taken a moderately 
severe cold. There is often a fever lasting until the eruption 
appears, with restlessness, sleeplessness, and peculiar shifting 
bodily pains. Anorexia is usually present. 

Whether it is generally true or not, the clinical observations 
seem to confirm the fact that in primary syphilitic infection in 
the throat, nose, or mouth, during the eruptive stage the ear- 
lier eruption is likely to appear on the palm of the hand ; while, 
in the general treatise on Syphilis, palmar eruption is generally 
cited as of infrequent early occurrence. 

Soon the symptoms of a coryza appear, varying proportionately 
with the severity of the disease ; sneezing, lacrimation, photopho- 
bia, dull headache, difficult respiration and perverted olfaction, 
gustation, and phonation may be met with. The nasal discharge 
is abundant, and at first is watery and thin. The membrane on 
inspection is red, swollen, and congested, and may be edematous 
— features most marked on the middle turbinate. The coryza 
increases in severity, the discharge becomes thicker, gradually 
acquires a somewhat fetid odor, and finally becomes almost or 
quite purulent, showing, perhaps, admixture with a slight amount 
of blood. The surface of the pituitary membrane, at first covered 
by thin secretion, shows here and there areas tending to extend 
and coalesce, which are covered by a greenish-yellow secretion. 
Later, mucous patches may be observed just within the vestibule, 
or at the cutaneous margins of the alee or the septum, or in the 
posterior nares, showing as slightly elevated areas, purplish-red or 
ashy in hue, ulcerated, surrounded by an inflammatory area, and 
usually covered by a yellowish secretion. The coryza is apt to be 
protracted, and usually resists any treatment save that directed 
against the specific disease. An important fact in the symptoma- 
tology is the coexistence of the various skin-eruptions and rashes. 

Tertiary. — The tertiary symptoms — if the disease, either 
through neglect or improper treatment, has reached this final stage 



NASAL SYPHILIS. 151 

— develop after a varying period, usually from five to twelve years, 
of complete absence of any manifestations, save, perhaps, the so- 
called " reminders." The mucous membrane gradually swells from 
cellular infiltrate and proliferation, either diffusely and involving 
areas of varying size, or in local nodules or gummata, situated 
usually in the respiratory region. The color is reddish or purplish- 
red, but later pales. The swellings, hard and firm at first, pit 
little under the probe, but later become softer. Pain may be 
present of a neuralgic character, due, not intrinsically to the 
growth, but to its continued presence and the protracted irritation 
of adjacent tissue. The usual symptoms of nasal obstruction 
develop. The further course of the disease varies. In some 
cases results ensue not dissimilar to those of atrophic rhinitis. 
The bony and cartilaginous structures necrose and undergo absorp- 
tion without breach of surface-continuity or secondary infection, 
and scar-tissue takes their place, subsequently contracting and in- 
creasing the nasal space. The secretion is diminished and inspis- 
sates, forming crusts, and there is a marked odor. The sense of 
smell is lost, and the wide-open cavities permit the free inhala- 
tion of unmodified air. In the majority of cases, however, ulcera- 
tion follows. The inflammatory masses break down, soften, and 
suppurate. The discharge increases, becomes abundant, often of 
a dark color, and is of a horrible and persistent odor, which disin- 
fectants fail to influence. Inspissation and crust-formation cause 
the membrane and ulcerated areas to be covered by dark-yellow- 
ish or yellowish-green scabs. Ulceration slowly spreads, forming 
large suppurative foci, with more or less overlying crust of dried 
secretion and necrotic shreds. Necrosis of the bone occurs, or 
has already occurred, and the discharge contains small, dark- 
greenish, " worm-eaten," and ill-smelling sequestra. If the probe 
be used upon these areas, distinct grating will be elicited, and 
fragments of diseased bone can be readily brought away. The 
process continues and, from the persistent loss of bony substance, 
grave structural changes are induced. The cartilage of the sep- 
tum melts down, and the tip of the nose falls in ; the vomer 
necroses, and the bridge flattens. The turbinates partly or wholly 
disappear. Perforation of the septum, or its complete destruc- 
tion, and perforation of the hard palate are by no means unlikely 
to follow. fc The process may involve the entire nose, and leave as 
nasal orifices two large gaps in the face, surrounded by cicatricial 
tissue. Perforation into the cranial cavity may occur. It is need- 
less to mention the changes that would obviously take place in 
the special senses, directly or indirectly connected with the nose, 
during such extensive tissue-involvement. The process may 
be unilateral or bilateral, and it may be in different stages in 
different sites at the same time, and, under appropriate treat- 
ment, healing of the ulcerated areas and the formation of stellate 



152 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

cicatrices result. Following healing of the ulcerated or absorp- 
tion of the non-ulcerated gummata, the scar-tissue of the cicatrix, 
in connection with the fibrous tissue formed adjacent to the gum- 
mata — a feature common to the specific inflammatory processes — 
constitute the areas of fibrous structure. As contraction takes 
place, however, the obliteration of the blood-supply may lead to 
degenerative changes in this tissue, forming the so-called areas of 
fibroid degeneration mentioned by various writers. 

Diagnosis. — Primary. — The primary sore in the nasal spaces 
by its very rarity renders the diagnosis often obscure. Usually an 
absolutely certain diagnosis can be made only upon the appearance 
of the secondary lesions. The history of the case may throw some 
light upon it. From a diagnostic standpoint the Wassermann re- 
action is of the greatest value. There is this, however, to be said 
of it, that if the reaction is a positive one, there is no question of 
the diagnosis ; if, on the other hand, the reaction is negative, it 
still leaves the question of diagnosis unsettled. 

Secondary. — The secondary manifestations in the nasal spaces 
may be so slight as to be overlooked. The diagnosis is based upon 
the history, symptoms, the constitutional manifestations, and the 
reaction to specific treatment. 

Tertiary. — The tertiary lesions of the nose present a picture 
that can scarcely be mistaken for anything else. The necrotic 
lesions, the intractable stench, the history of the case, and the 
prompt response to the iodids should make the diagnosis com- 
paratively easy. 

Prognosis. — Under proper treatment instituted during the 
secondary stage, the chances of recovery are extremely good. 
During the tertiary stage, if the necrosis is not excessive and 
vigor is fairly unimpaired, early treatment offers good chances for 
recovery. The prognosis becomes graver, however, in proportion 
to the severity and extent of the lesions and the length of time 
that they have been untreated. After recovery, the cicatricial 
tissue formed may cause impairment of various associated func- 
tions. 

Complications. — Necrosis into the cranial cavity may occur, 
or partial destruction of the sphenoid, ethmoid, occipital, and supe- 
rior maxillary bones. 

Treatment. — Primary. — The treatment of nasal chancre 
should consist in thorough cleansing by the use of a warm alka- 
line solution described on page 135. followed by mopping the 
lesion with — 

3^. Extracti hydrastis (aqueous, colorless), 3ij (7.5) ; 
Hydrogeni peroxidi, 
Aquse cinnamomi, da fl^j (30.). 



NASAL SYPHILIS. 153 

The ulcer is never to be cauterized or excised. The enlarged 
glands should be smeared with equal parts of ichthyol and lanolin, 
or painted with tincture of iodin. No mercury is to be given in 
this stage of the disease, for the reason that, by the suppression 
of the secondary eruption, proper diagnosis is interfered with, and 
from the uninfluenced secondary lesion a more definite prognosis 
can be given. 

Secondary. — For the coryza of secondary syphilis local medi- 
cation is of little or no avail. The mucous patch should be 
thoroughly cleansed with equal parts of hydrogen peroxid (15 
volume) and cinnamon water, and touched daily with the solid 
stick of nitrate of silver or with nitric acid applied on sharp- 
ened bits of wood. The constitutional treatment should now 
be instituted and kept up uninterruptedly for two years, in 
the form of the protiodid in doses of -^ grain, as the green 
iodid in -1-grain doses, or as the bichlorid in ^__grain doses. 
Mercury is to be administered three times a day. On the 
second day the morning dose is to be doubled, on the third 
day the noonday dose is to be doubled, and so on, increasing 
the dose of each entire clay by the size of the original dose 
until there is slight diarrhea, griping, a metallic taste in the 
mouth, or soreness on snapping the teeth together, when the day's 
dosage should be reduced by the same increment as it was increased, 
until these symptoms cease. This is the point of tolerance for 
each individual and is the maximum dose. 

Tertiary. — Local. — The tertiary ulceration of the nasal cavities 
is to be cleansed by the application of hydrogen peroxid (15 vol- 
ume) by means of the atomizer or cotton-covered probe. After 
thorough cleansing, the involved areas should be touched with 
the solid stick of nitrate of silver, and, if they tend to proliferate, 
they should be excised or burned with the actual or galvano- 
cautery. If the deeper structures be involved, they should be 
carefully curetted and pieces of loose bone removed. The dis- 
agreeable odor arising from the destructive nasal processes can be 
controlled by douching with — 

1^. Potassii permanganatis, gr. ij (.12) ; 

Acidi borici, gr. v (.3) ; 

AquaB (tepid), flgj (30.) ; 

every three or four hours. 

Constitutional. — The constitutional treatment of the so-called 
" late secondary " or tertiary stage of syphilis should consist mainly 
in the administration of the iodid of potassium or sodium and 
mercury. The best method of obtaining results, gratifying alike 
to physician and patient in the administration of these drugs, 
is to prescribe the iodid of sodium in a saturated solution, com- 



154 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

mencing with 20 grains three times daily in a half-glass of milk 
at least a half-hour after meals. Give the mercury in the form 
of the bichlorid in compound syrup of sarsaparilla, commencing 
with I lg- to -|-grain doses at the same time as the iodid. By 
giving these drugs in this manner, the dose of the iodid may be 
increased or decreased at will, without affecting the size of the 
dose of mercury, or adding more sarsaparilla to disorder the diges- 
tion. The iodid may be increased by large amounts, 20 grains 
at a dose, or by smaller amounts, 5 grains, as the case requires. 
Iodism may be guarded against by administering 5 to 10 grains 
of sodium bromid with each dose of the iodid, as recommended 
by Bosworth, or by discontinuing the use of the drug on the 
appearance of the " iodic " rash or coryza. In individuals 
who cannot take iodids on account of the rash produced, if one 
hour before administration of the iodids there is given -J grain 
of the extract of belladonna, this disagreeable effect can be 
avoided. 

The use of alcohol (as a beverage) and tobacco is to be inter- 
dicted ; outdoor life is to be insisted upon. A stimulating diet 
should be prescribed. Any falling off in weight calls for the 
addition of tonics. One of the best formulae for administration 
in conjunction with the specific treatment given above is — 

3^. Pulveris kola?, gr. iij (.18); 

Ferri lactatis, gr. j (.06) ; 

Strychninse nitratis, gr. -^ (.002). — M. 

given in pill or capsule three times a day. Nasal deformity is to 
be guarded against by careful prophylactic treatment. If the case 
is seen after the bridge of the nose has sunken in, an artificial 
bridge may be inserted, or modified Mayer's tubes, of a shape 
adapted to each case, may be worn, obtaining the desired form by 
taking an impression with dental wax. When the cartilaginous 
support of the end of the nose has been destroyed so as to let the 
tip fall upon the upper lip, Bishop has restored the natural shape 
by using his nasal supporter of vulcanized rubber with admirable 
results. 

The method suggested by Gersuny for the correction of such 
nasal deformities by paraffin injection is applicable in a certain 
variety of cases. If the soft tissues are not too badly ulcerated, 
this method can be used to great advantage. The secret of the 
success of the paraffin method seems to lie in the prevention of 
infection and in injecting a small amount of paraffin at a time. 
From an analysis of cases reported, the bad results obtained 
seem to be traced to one or the other of these points. There is, 
however, considerable danger of embolism forming, and there are 
cases on record in which such condition has occurred in the lung 



NASAL SYPHILIS. 



155 



following the paraffin injection. Of the instruments for the in- 
jection of paraffin those shown in Figs. 61 and 62 are among the 
best. Fig. 61 is an ordinary glass antitoxin syringe with a needle 
of large caliber. The syringe is encased in a metallic hood, through 
which flows water at a temperature of from 118° to 125° F. 
This hood can be fed from a receptacle holding a considerable 

quantity of water at the tem- 
perature desired. This will 
keep the paraffin at the proper 
temperature. The advantage 
of the glass instrument over 
the metallic one is that the 
contents of the barrel can be 





Fig. 61.— Quinlan's syringe for the injection 
of paraffin. 



Fig. 62.— Paraffin syringe. 



seen at all times. The paraffin must be carefully sterilized, as 
asepsis is one of the important elements in the employment of this 
remedy. 

The skin for some distance about the point of puncture should 
be thoroughly cleansed with a strong antiseptic solution ; in fact, 
the same preparation must be made as for any surgical operation. 
Care must be taken that too much fluid is not forced into the 
tissue at one time, as it is much better to make subsequent injec- 
tions rather than to render the tissues tense by overdistention 
with the paraffin ; besides, there is danger of cutting off the nutri- 
tion to the cells and causing necrosis with ulceration. The fluid 
after injection can be molded into any desired shape, and should 



156 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

not be allowed to cool too quickly. Some have made the mistake 
of applying cold to the tissue. Instead, heat should be applied 
and the temperature gradually lowered to that of the body. There 
will be less danger of secondary congestion with subsequent edema- 
tous infiltration. The pathological change, or rather the physio- 
logical change, which occurs in the tissue seems to be that of 
encapsulation, through the forming of connective tissue around 
the paraffin. Gersuny's original method was to force the semi- 
fluid paraffin into the tissue, allowing the melted paraffin to par- 
tially cool in the syringe, and forcing it into the tissue in the form 
of a fine thread from the small syringe-needle. He maintained 
that in this way there was less possibility of paraffin-embolism. 

My own experience with this method has been limited, but I 
have been fortunate enough to see some of the results obtained by 
other operators, and I think that they correspond very well with 
my own — that in certain selected cases, where the tissue is in 
a fairly healthy condition, where there is very little scar-tissue, 
and where there is sufficient soft tissue remaining in the nose to 
afford support to the paraffin, the operation will be fairly success- 
ful. If, however, there is much scar-tissue present, or any ulcer- 
ation within the nasal cavity, the paraffin method should not be 
attempted. 

Important points in the paraffin method are : 

1. Asepsis. 

2. Paraffin that will melt at 38° or 39° C. 

3. Do not use the paraffin too hot. 

4. Insert the needle as far from the depression as is possible 
(this may be at the tip of the nose or just within the nostril), car- 
rying the needle up subcutaneously to the point of depression. 

5. Do not use too much paraffin at a time ; repeated injections 
can be made. 

Salvarsan and Neosalvarsan in Syphilis of the Nose 
and Throat. — While sufficient time has not elapsed since the 
introduction of salvarsan in the treatment of syphilis to enable one 
to draw any definite conclusions as to its permanent effect, as ob- 
viously years must elapse before a final judgment can be pro- 
nounced, yet from the results obtained from its administration in 
many thousand cases, and from my own experience, there is no 
doubt as to the powerful effect of the drug in dissipating the clinical 
symptoms of syphilis in its various manifestations. 

As Browning and McKenzie have pointed out : " It is impor- 
tant to keep in view the morbid anatomy of the disease and the 
distribution of the spirochetes in the body. Were syphilis a blood 
infection, like relapsing fever, we could predict with practical cer- 
tainty the complete sterilization of the tissues and consequent cure 
of the disease by means of salvarsan, so marked are its spirillicidal 
properties. But this is not the case. Syphilis is essentially a tis- 



NASAL SYPHILIS. 157 

sue disease, though the spirochetes are also carried by the blood 
stream ; the organisms have a special preference for dense connect- 
ive-tissue structures, and embedded in these or at the margin of 
caseous lesions they may remain alive, though inactive, for years. 
If these points be kept in view, the difficulty of bringing the drug 
efficiently into relation with the spirochetes will be readily appre- 
ciated, especially when it is borne in mind that probably the drug, 
as indicated by the arsenic excretion in the urine, has disappeared 
from the blood within three or four days after intravenous injec- 
tion." 

Of all syphilitic lesions those involving the nose and throat give 
by far the most rapid and satisfactory results from the administra- 
tion of salvarsan. The greater the blood-supply to the diseased 
tissue, the more rapid and effective will be the results obtained by 
this method of treatment. The rapidity with which nose and 
throat lesions disappear can thus be accounted for by the abundant 
blood-supply to these structures. Likewise, broken-down tissue 
in the tertiary stage of the disease often gives much better results 
than intact lesions, such as gummata. 

On the other hand, the more deeply the spirochetes are located 
in the tissues, the less rapid and efficient are the results obtained 
from the administration of salvarsan. Tertiary lesions occur most 
frequently in comparatively dense tissue, and the process in this 
stage is more or less to wall off the lesions from adjacent struc- 
tures. This walling-off process, as in the case of gummata, de- 
creases the blood-supply to a marked extent, and the salvarsan in 
the blood-stream has far less ability to reach the spirochetes and 
thus exerts its antisyphilitic properties upon them. 

Therefore, in tertiary lesions, iodid of potassium, in conjunction 
with salvarsan, plays a very important part in the treatment of the 
disease. It is a well-known fact that iodid of potassium has the 
peculiar power of breaking down this walling-off process, and by 
establishing free access for the blood to enter the tissues permits 
the salvarsan to come in contact with the spirochetes and thus ex- 
ert more fully its spirillicidal powers. 

It has been claimed that salvarsan ceases to have any potency 
after five days have elapsed. If this is true, mercury, in conjunc- 
tion with the iodids, is an important factor in destroying the spiro- 
chetes left unharmed by the salvarsan. At the present time many 
syphilographers advocate the administration of a course of mer- 
curial treatment following the injections with salvarsan. 

Salvarsan is indicated in all lesions of the nose and throat in 
which a positive Wassermann reaction is obtained. It must be 
remembered, however, that a certain percentage of cases which are 
specific will give a negative Wassermann test. Therefore, if the 
serum reaction is negative, and our clinical experience leads us to 
believe the lesions to be specific, and provided all other causative 



158 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

factors have been eliminated by exclusion, then salvarsan is still 
indicated. 

Syphilitic lesions of the nose and throat, whether they be pri- 
mary, secondary, or tertiary, respond most satisfactorily to the 
administration of salvarsan. Primary and secondary symptoms 
clear up very rapidly, and tertiary lesions give nearly as good re- 
sults. Bone lesions of the roof of the mouth and nose recover 
nearly as rapidly as those of the mucous membrane and muscles 
of the throat. Exudates on the tonsils disappear in a day or two, 
while the severe inflammatory swelling of the tonsils recedes usu- 
ally in a week. The hoarseness which often accompanies syphilitic 
lesions of the throat disappears, as a rule, in three to five days. 
The pain which is often associated with lesions of the throat fre- 
quently disappears a few hours after injection. Tertiary bone 
lesions in a state of inflammation are usually very rapid in their 
recovery, as well as broken-down tissue in the same stage. 

The rapidity with which the drug acts in clearing up ulcerative 
conditions in the secondary and tertiary stages makes it particularly 
valuable in nose and throat cases, as results are obtained from one 
injection which previously required four or five months' treatment 
with mercury and iodids. This is of the greatest importance when 
we are dealing with rapidly progressing lesions which threaten ex- 
tensive destruction of the tissues. Previous to the advent of sal- 
varsan I have observed cases of syphilitic ulceration of the nasal 
septum and the palate which would destroy these tissues before the 
disease could be gotten under control, notwithstanding heroic doses 
of mercury and iodids were administered, while at the present 
time the employment of salvarsan in these cases results in an 
almost immediate arrest of the process and thus the integrity of 
the tissues is preserved. 

The contra-indications to the administration of salvarsan are 
diseases of the central nervous system affecting vital organs, espe- 
cially when associated with degenerative changes, a tendency to 
cerebral hemorrhage, myocarditis, arterial degeneration, aneurysm, 
old age, severe nephritis, diabetes, and gastric ulcer. Visceral 
affections of syphilitic origin are not to be considered as contra- 
indicating the use of the drug, as good results have been reported 
following the injections in such cases. At first it was considered 
inadvisable to employ this treatment in eye affections, but more 
recently it has been used with brilliant results in all varieties of 
syphilitic diseases of the eye. 

The intravenous injection is the method which I have em- 
ployed in all my cases, and this is now conceded to be the most 
satisfactory way of administering the drug. Salvarsan is used in 
the form of the alkaline solution, which is prepared in the follow- 
ing manner : 

The glassware used is carefully sterilized by boiling. The con- 



NASAL SYPHILIS. 159 

tents of the ampule (0.6 gm. of the drug) is placed in a 30 c.c. 
stoppered cylinder, to which is added about 15 c.c. of sterile normal 
saline solution, previously heated to 50° C, and then thoroughly 
shaken until the drug is in solution. The saline solution should be 
prepared from chemically pure sodium chlorid and freshly distilled 
water. There is then added, drop by drop, a 10 per cent, solution 
of caustic soda to the solution in the cylinder. At first a precipitate 
of the base is thrown down, and on the further addition of caustic 
soda, aided by shaking, this is again brought into solution, the 
solution being strongly alkaline. The amount of caustic soda 
necessary is approximately 0.25 c.c. of 10 per cent, solution for 
each 0.1 gm. of salvarsan; thus, for 0.6 gm. of salvarsan, 1.5 c.c. 
would be required. One drop more of alkali than is just necessary 
to produce the clear solution should be added. Should the diluted 
solution show a precipitate, this can be redissolved by the addition 
of a drop of alkali. The drug, being in the form of a clear alka- 
line solution, is poured into a graduate through several layers of 
sterile gauze to remove any suspended matter, and the residue in 
the stoppered cylinder is washed out into the graduate with a small 
quantity of saline solution. The solution is now diluted with 
normal salt solution to 300 c.c, and the graduate placed in a suit- 
able vessel containing hot sterile water to keep it at the required 
temperature. AVhen injected, the solution should be at exactly 
the body temperature. It will be seen that in this dilution of 
300 c.c. each 50 c.c. contains 0.1 gm. of the drug, and the dose 
can be regulated accordingly. 

Neosalvarsan is also given by intravenous injection, and is pre- 
pared by simply dissolving the contents of the ampule (0.9 gm. of 
the drug, which is equivalent to 0.6 of salvarsan) in 200 c.c. of 
sterile saline solution at a temperature of 70° F. in a sterile 
graduate. The solution should be injected immediately, as rapid 
oxidation takes place if allowed to stand. 

The apparatus necessary for the injection comprises a cylin- 
drical funnel of 300 c.c. capacity, to the narrow lower end of which 
about 5 feet of rubber tubing is attached. This tubing is inter- 
rupted about 18 inches from its attachment to the cylinder by a 
piece of glass tube to act as a window. At the other end of the 
tubing there is an arrangement whereby it can be easily fixed on 
to the needle used for venipuncture. The apparatus is sterilized 
by boiling. Immediately before use the tubing is fixed on to the 
glass cylinder and the apparatus washed through with warm sterile 
saline solution. A screw clamp is placed on the tubing about 3 
inches above the nozzle and the clamp fixed, leaving the whole 
upper portion of the tube filled with saline solution, and, in addi- 
tion, about 10 c.c. in the cylinder. 

The skin in the region of the forearm and elbow having been 
sterilized, the arm is allowed to hang down for a few minutes, and 



160 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

a tourniquet, preferably a piece of rubber tubing with a hemostat 
for a clamp which can be quickly removed, is placed on the arm 
above the elbow. A prominent vein on the flat surface of the arm, 
usually below the elbow, is selected, and a needle of 1.0 mm. to 
1.22 mm. external diameter is introduced into the lumen in the 
direction of the blood-stream. The free flow of blood indicates 
that the needle has been properly inserted, and one can easily rec- 
ognize by the sense of touch whether the needle is resting freely 
in the lumen. The tourniquet is removed as soon as the needle 
has been properly introduced. The clamp on the rubber tubing 
is now released, and while the blood is flowing from the vein and 
the saline solution from the tubing, the nozzle of the latter is fixed 
on to the needle. The cylinder is then raised so as to allow the 
solution to flow into the vein. If the needle has not been properly 
introduced, this reveals itself by the appearance of a swelling. 
Should this occur, the needle must be withdrawn at once and 
another vein punctured. When the saline solution flows freely 
into the vein, the salvarsan solution is carefully poured into the 
cylinder so as to avoid the entrance of air into the tube. If the 
solution appears to be falling too slowly in the cylinder this may 
be remedied by turning the needle in the vein, as the aperture 
may have become applied to the wall of the vein. After the de- 
sired quantity of the solution has been introduced into the vein, 
the needle is quickly withdrawn and sterile dressings applied with 
a firm bandage. 

A few hours after the injection certain reactive phenomena 
manifest themselves. There is usually a rise in temperature, 
ranging from 99° to 103° F., or even higher. The temperature 
rises higher in patients who have had malaria. The patient may 
experience rigors, sweats, nausea, vomiting, thirst, diarrhea, rapid 
pulse, and headache. In some instances the headache is very 
severe. One of my cases complained of a severe cramp in the 
muscles of the calf of the leg a few hours after the injection. In 
some cases an arsenic rash in the form of an erythema follows in- 
jection. The Herxheimer reaction has been noted by some 
observers, and consists in the development of a rash, or the exten- 
sion or intensification of a rash already present, as the result of the 
treatment. This was not observed in any of my cases. The reac- 
tion has been attributed either to the eifect of endotoxins liberated 
from spirochetes destroyed as the result of the drug, or to a stimu- 
lation of the spirochetes by a dose of the drug which did not suffice 
to cause their death. However, it does not seem to have any 
bearing on the effectiveness of the treatment. In all of my cases 
in which there was an active lesion in the nose or throat the 
patients have complained of more or less severe pain at the seat of 
the lesion shortly after the introduction of the salvarsan. 

While there is an almost universal concensus of opinion as to the 



NASAL SYPHILIS. 161 

efficacy of salvarsan in removing the clinical manifestations of 
syphilis, the evidence regarding the influence of the drug on the 
Wassermann reaction is very conflicting. It may be stated, how- 
ever, that a positive reaction can be converted into a negative one 
in every case, provided a sufficient number of injections of salvar- 
san are given. In many of my cases the reaction became negative 
after one injection, while in others a second or third injection was 
required. The period of time required for this conversion of a 
positive into a negative reaction may depend largely upon the 
strength of the reaction at the time of treatment and the size of 
the dose employed. The facility with which a positive serum re- 
action can be transformed into a negative one also varies at differ- 
ent stages of the disease. The earlier the cases are treated the 
more readily is a negative reaction obtained. As a rule, the 
Wassermann reaction becomes negative in from four to six weeks 
following the injection. In congenital syphilis it has been found 
that the injection of salvarsan produces a negative serum reaction 
in only a very small proportion of cases. 

Some observers have seen a negative Wassermann reaction, after 
the administration of salvarsan, change back to positive. Accord- 
ing to McDonagh, " the negative reaction produced by the admin- 
istration of salvarsan may at any time become positive before the 
appearance of clinical symptoms ; therefore, unfortunately, no 
guarantee can be given to a patient, however long his blood has 
been negative. All that is meant by producing a negative reaction 
is that the patient has been transferred from an active into a latent 
syphilitic state. So long as the disease is latent, it may at any 
time become active again. The proof that cases giving a negative 
Wassermann reaction are not necessarily cured is that a positive 
reaction can be almost invariably obtained within forty-eight hours 
by giving an intravenous injection of salvarsan, a so-called provo- 
cative injection. Not only will the reaction be positive, but it will 
vary in degree and length of time that it is demonstrable. A 
weak positive reaction in the early stages of the disease signifies 
that the previous treatment has been good ; therefore, less will be 
required to cure the- patient. This shows the importance of early 
and vigorous treatment." 

Many cases have been reported in which only a temporary re- 
mission in the symptoms has been produced, and recurrences have 
occurred following the injection of salvarsan. As time passes 
more of these recurrences will certainly be observed. Several 
cases have been recorded which proved refractory to the treatment 
from the start, but these must be considered comparatively rare. 
Various instances have been reported in which these recurrences 
have manifested themselves in the form of lesions of the cranial 
nerves, especially the optic and auditory, the so-called neuro- 
recurrences. Some observers have been inclined to attribute such 
11 



162 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

recurrences to a toxic influence of the drug on these organs. It 
is certain, however, that these are not toxic manifestations, since 
they are unilateral and improve under a second injection or the 
administration of mercury. I believe these disturbances to be of 
the nature of a recrudescence consequent upon the failure of the 
drug or its spirillicidal products to reach comparatively avascular 
tissues in which the spirochetes have been localized. One of my 
cases developed a unilateral involvement of the auditory apparatus 
two months after injection. 

While I do not believe that salvarsan is absolutely curative, it 
possesses marvelous symptomatic efficiency and is far in advance 
of the older methods of treatment, often relieving in a surprisingly 
short time lesions which have resisted enormous doses of mercury 
and iodids. Personally, I would consider that no case of syphilis 
of the nose and throat has been thoroughly treated unless salvar- 
san or neosalvarsan has been administered. 

Hereditaby Syphilis. 

Definition. — By hereditary syphilis is meant that form of 
syphilis in which the infection takes place before birth. In the 
early form it appears usually prior to the third month, and its 
manifestations may be considered as being of the secondary type. 
The late form appears at or before puberty, and is generally of 
the tertiary type. 

Synonyms. — Congenital syphilis of the nose ; Inherited syph- 
ilis of the nose. 

Special Synonyms. — Early, Snuffles ; Late, Syphilis tarda. 

etiology. — This may be briefly summed up in the terse state- 
ment, "parental transmission." The poison may be transmitted 
through the father, in which case the term sperm-inheritance is 
employed, or it may be conveyed by the mother, the so-called 
germ-inheritance, and in not a few cases both parents have been 
syphilitic. The student must not forget, however, that syphilis 
arising from inoculation during the passage of the child through, 
the birth-canal is the acquired, not the hereditary, form. 

Pathology. — Early. — The pathology of this stage is the same 
as that already described in the pathology of the secondary 
acquired form, with the exception that the inflammation is rela- 
tively more intense, and in the smaller nasal spaces of the young 
child is productive of more marked phenomena. Necrosis and 
absorption of bone and cartilage may occur as the result of a 
deeper extension of the inflammatory process. It is probable that 
the flattened nasal bridge characteristic of this period is a mal- 
development consequent upon the reaction of the young tissue to 
the inflammatory process. 

Late. — The pathology is identical with that of the tertiary 



NASAL SYPHILIS. 163 

lesions of the acquired form. Gummatous formation, ulceration, 
necrosis, and discharge or absorption of the tissues occur in pre- 
cisely the same manner. 

Symptoms. — Early. — In the second or third week after birth, 
sometimes earlier, but rarely later than the third month, the child 
gives evidence of a severe rhinitis. The mucous membrane of the 
nose is red and swollen. There is an abundant discharge of a clear 
watery character, which is very irritant and excoriates the surface 
with which it comes in prolonged contact. Later, it becomes muco- 
purulent, thickens, and tends to the formation of crusts. If the 
disease follows a severe course to ulceration and necrosis, the dis- 
charge becomes purulent, admixed with blood, contains shreds of 
necrosed tissue, and possesses a characteristic fetid odor. Fissures 
at the angles of the ala? and upon the nasal margins develop. 
Noisy breathing from the nasal obstruction is a pronounced symp- 
tom, giving origin to the popular designation of " snuffles," and 
the mouth is used more or less as a respiratory adjunct. Suffo- 
cative spasms during sleep are not uncommon, and the child can- 
not nurse properly. Mucous patches are liable to occur at the 
angles of the nostrils and in the membrane of the nose, and in 
some cases necrosis of the nasal framework develops. A pecul- 
iar pathognomonic flattening of the nasal bridge occurs, which 
is probably a maldevelopment from inflammatory interference 
with the proper growth of tissue. The constitutional involvement 
is severe. The child is at birth ill-nourished and weazened, or 
rapidly becomes so. The impaired nursing ability rapidly de- 
creases its nutrition, and the inhalation of noxious gases and 
unconscious swallowing of fetid secretion still further impoverish 
its vitality. The characteristic skin-lesions are present — a sallow, 
muddy, unhealthy hue, and the varied eruptions. In hereditary 
specific lesions of the tissues of the nose, nasopharynx, and 
pharynx the frequent lesion early manifested is the soft gumma, 
also enlargement of the glands. In children this is usually 
noticed in the cervical and submaxillary gland. Hutchinson's 
teeth are not always present. The child may have gumma of 
the soft palate or nasal septum without any involvement of the 
neck. In children with ulceration and even lesions of the bony 
structure about the nose, before operation the question of syph- 
ilis should be entirely eliminated by the therapeutic test. This 
test should invariably be carried out in all cases of lesions of 
the throat, pharynx, and larynx, in fact, of the upper respira- 
tory tract, especially new growths. Mucous patches are com- 
mon, especially at the various mucocutaneous junctions, and 
the hair and nails are aifected. The child is restless, yawns 
frequently, sleeps badly, and its voice acquires a characteristic 
shrill pitch. A terse, pathetic, and comprehensive picture of a 



164 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

child with inherited syphilis is painted in the following sentence : 
" A little, dried-up old man with a cold." 

Late. — The late manifestations of hereditary syphilis appear 
between the third month and puberty, and do not differ from the 
symptoms which we have already described as characteristic of 
the tertiary acquired form. There is the same inflammatory infil- 
trate into the nasal mucosa, which causes a diffuse swelling or 
takes the form of small gummatous nodules. These undergo pre- 
cisely the same processes of softening and absorption or ulceration 
and necrosis. The nasal discharge becomes purulent, blood- 
streaked, thick, dark, and extremely offensive. It becomes mixed 
with shreds of necrosed tissue and sequestra of diseased bone. 
Crusts form, which are dark and ill-smelling. Extensive osseous 
and cartilaginous destruction follows with perforation of the sep- 
tum or hard palate, and more or less facial deformity from 
destruction of the bony support. The patient's general health is 
impaired, and the constitutional exhibitions of the disease in their 
various other local manifestations are present. 

Diagnosis. — Early. — The early form is usually pathognomonic 
in its symptoms, and can scarcely be mistaken for any other affec- 
tion. The parental history, obstinate coryza, general facies, and 
reaction to specific treatment form the chief points. 

The Wassermann reaction, as referred to on page 152, is of the 
greatest value from a diagnostic standpoint. 

Late. — The diagnosis is usually not difficult. The progressive 
nasal-tissue destruction, the characteristic and horribly offensive 
odor, the response to alterative treatment, the general manifesta- 
tions, and the history of the case should make it clear. Lupus 
may confuse, but this is slower in growth, is associated with the 
tubercular diathesis, attacks cartilage only, does not invade the 
hard palate, and has not so pronounced an odor. Specific treat- 
ment gives a decided diagnostic test. 

Prognosis. — Early. — The prognosis of the disease at this stage 
depends upon its general severity and the strength and nutrition 
of the child. Proper specific treatment, in the milder cases, and 
good management of trie nutrition offer a very fair prognosis. 
Severe cases, on the other hand, ill-nourished and with gastro- 
intestinal disorder, offer but little chance of recovery. Statistics 
would seem to indicate a relation between the transmission of the 
disease and the mortality. If transmitted from the father, the 
death-rate slightly oversteps 25 per cent. ; from the mother, about 
60 per cent. ; and if both parents are syphilitic, it rises to nearly 
70 per cent. 

Late. — The prognosis of this form of syphilis depends upon 
the strength of the patient, upon the extent and the severity of 
the necrotic changes, and upon the early treatment of the disease. 
In the early stages, before extensive loss of tissue and general 



NASAL SYPHILIS. 165 

weakening of the patient occurs, the prognosis under treatment is 
good. Later, however, the extension of the unmodified process 
renders the prognosis proportionately grave. 

Treatment. — Local. — The treatment of hereditary syphilis 
should consist locally in thorough cleansing of the nasal cavities. 
This can be effected as described under the treatment of acute rhi- 
nitis in children (page 92), using as the astringent and deodorant 
solution either — 

R. Aeidi borici. gr. v (.3) ; 

Potassii permanoanatis, ' gr. j (.06); 

Aquae, fl?j (30.); 



or, 



E.. Acidi carbolici, gr.j(.06); 

Sodii bicarbonatis, gr. vj (.36) ; 

Acidi borici, gr. v (.3) ; 

Aqua?, flg (30.). 

Morell Mackenzie's method of obtaining a similar result is : " The 
child should be placed in the nurse's lap and the nasopharynx 
plugged by means of the temporary sponge tampon. The little 
patient's head should then be slightly raised and the nose washed 
out with a fine syringe, or. if it be preferred, a spray or nasal 
douche can be used, care being taken in the latter case that too 
much force is not employed." For cleansing purposes, warm 
milk, to which is added 3 to 5 grams of sodium chlorid to the 
ounce, may be employed. 

Constitutional. — The constitutional treatment of this form of 
syphilis should consist, first, in the administration of mercury in 
the form best suited to the case. There should be rubbed in the 
sole of each foot or the palm of each hand 5 grains of the mer- 
curial ointment every morning and night, as advised by J. Chal- 
mers Da Costa ; or the ointment, in the strength of 1 dram to the 
ounce, may be spread on the belly-band, renewing the application 
daily. Mackenzie prefers mercury with chalk in doses of 1 to 
2 grains twice daily. If diarrhea is set up, 1 grain Dover's 
powder or an additional grain of chalk should be combined with 
each dose of the gray powder. "Any of these remedies are to be 
used until the symptoms disappear, but mercury must not be forced 
or continued too long after the symptoms are gone" (Da Costa). 
On the appearance of tertiary symptoms give from ^ to 1 grain 
or more of iodid of potassium several times a day in milk. 
AVhite recommends the continuation of the mixed treatment inter- 
mittently until puberty. As adjuvant tissue-builders give cod- 
liver oil, the syrup of the iodid of iron, or the double sulphid of 
arsenic, the last named in ^- to ^L-grain doses, according to the 
age and size of the child. An admirable medicament for con- 



166 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

structive metamorphosis is lactophosphate of lime in 1-dram doses 
every four hours. 

NASAL TUBERCULOSIS. 

Definition. — An extremely rare, chronic infectious inflamma- 
tory disease of the nose, due to a specific organism. The disease 
is marked by the formation of the characteristic tubercular ulcers 
on the nasal mucosa, or by the growth of tubercles forming tumors 
of varying size, which subsequently break down and ulcerate. 
These manifestations may coexist. There is an increased nasal 
discharge, which is markedly fetid. The disease runs a slow, pro- 
tracted course, modified little, if at all, by treatment. 

Synonyms. — Nasal phthisis ; Phthisis nasalis ; Tuberculosis 
nasalis. 

Etiology. — Nasal tuberculosis is extremely rare, compara- 
tively few cases being recorded in medical literature. 

Predisposing" Causes. — The majority of cases occur in those 
possessing the tubercular diathesis. As a rule, also, the disease is a 
secondary infection from tubercular lesions elsewhere. All con- 
ditions of the nasal mucosa in which abrasions occur, as well as 
lowered bodily resistance, play important predisposing parts. Con- 
genital or acquired malformation of the nasal space, favoring 
lodgement of the inspired germ, must not be overlooked. Age, 
sex, etc., have no bearing as to its occurrence. The disease is, 
however, contagious, and occupations necessitating contact with 
those suffering from it, especially in rooms inhabited by them, 
filled with germ-laden dust, predispose to no slight extent. 

Exciting- Causes. — The specific organism is known as the 
Bacillus tuberculosis, or, as it is sometimes called, the bacillus of 
Koch. This is a straight or slightly curved rod, often beaded, 
with rounded ends, non-motile, and reproducing probably only by 
fission, though spore-formation has been claimed to take place. A 
peculiarity of the germ is its behavior to stains, staining slowly 
with alkaline fluids, and not decolorizing with dilute acid solutions. 
This property is explained by the shrinkage of the germ in the 
thin investing capsule by the action of the acid. Primary infec- 
tion of the nose is extremely rare, and requires the lodgement of 
the inspired germ upon an abraded surface for its inception. That 
it does not occur oftener is possibly due to the fact that, in the 
greater number of instances, the germ when so deposited is washed 
off by the nasal secretion. Secondary infection may take place 
through the blood- or lymph-channels, by continuity or by con- 
tiguity of structure. Usually it follows infection occurring in the 
lower part of the respiratory tract, the germ being deposited on 
abraded areas in the nose, in small portions of expectorated mate- 
rial, during a violent fit of coughing. 

Pathology. — Macroscopically the morbid process may take 



NASAL TUBERCULOSIS. 167 

the form of a diffuse swelling from general tubercular inflamma- 
tory infiltration, or the more characteristic form of development ; 
in either, miliary nodules may be seen, which may later coalesce 
into a single growth, or the formation of single tubercles. In 
either form, the process sooner or later by its growth destroys its 
nutriment, liquefaction-necrosis follows with ulceration, and mixed 
infection occurring, a typical tubercular ulcer results. The ulcers 
spread slowly, and frequently in their floors and margins small 
miliary tubercles may be seen, which undergo the same softening 
and breaking down, and add to the ulcerated area. Usually there 
is more or less evidence of a surrounding inflammatory action. 
Microscopically there is found a great number of small round 
lymphoid cells, numerous epithelioid cells, and some giant cells. 
The tubercle bacilli may be present in small numbers. The cells 
tend to collect in masses, which through their proliferation in- 
crease in size and exercise considerable pressure. As a result, 
there is mechanical interference with the blood-supply, and finally 
it is obliterated, and the mass undergoes liquefaction-necrosis and 
subsequent ulceration. The microscope also shows considerable 
involvement of the glandular structures by the pressure of the 
infiltrate. Some of the glands are distorted, others obliterated, 
still others show desquamation of their secretory epithelium. The 
infiltrate thus collecting also acts as a foreign body, and the sur- 
rounding tissue shows inflammatory phenomena. The tubercular 
tumor varies from small nodules the size of a pin-head, to those as 
large as a pea. They grow slowly and present appearances which 
vary according to the stage of development or retrogression. 
Usually the growth is single, but it may be formed by the coa- 
lescence of several miliary nodules. At first firm to the touch 
and attended by considerable hyperemia, they later become 
softer and paler as degenerative changes ensue and the blood- 
supply lessens. They have usually a broad base, and a sur- 
rounding zone of inflammation is present. The morbid his- 
tology is the same as that of tubercle anywhere, with perhaps 
slight modification from the vascularity of the nasal site. There 
is the same growing mass of small round cells, of epithelioid and 
giant cells, and lying between or sometimes within the cells are 
bacilli more or less numerous. Later the vascular supply is ob- 
literated, the mass undergoes liquefaction-necrosis, beginning at its 
center and extending to its periphery, partial absorption of the 
fluid may occur and caseation result. Usually the overlying 
tissue breaks down, and discharge of the cheesy contents, together 
with pyogenic infection, produces the typical tubercular ulcer. In 
some cases, both in this and the preceding form of tubercular 
lesion, attempts at healing may occur, and proliferation and 
organization of inflammatory tissue into a fibrous cicatrix may 
result. Such formation, however, is extremely apt to undergo fur- 



168 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

ther tubercular breaking down at a later stage. There is gener- 
ally more or less of a fibrous thickening in the tissue surrounding 
the tubercle, due to simple inflammatory organization. 

Symptoms. — The disease being usually secondary to other 
tubercular lesions, the constitutional condition may be impaired 
proportionately to the extent and severity of the primary disease. 
This necessarily gives a wide range of symptoms, from the slight 
evidences of hereditary tendency, intensifying with the progress of 
the morbid process, to the distressing picture of emaciation, hectic 
flushes, racking cough, and profound exhaustion of the later stages. 
Locally the onset is insidious. In the ulcerative form, the process 
begins usually as a small ulcer on the anterior portion of the sep- 
tum, which slowly spreads over the septal surface to the floor of 
the fossa, but rarely to the turbinated surfaces. It may extend 
beyond the mucocutaneous junction and attack the upper lip. In 
shape, the ulcerating area is round or ovoid, its edges are irregular 
and uneven, and may be slightly raised or on the same level with 
the adjacent surface. It may be difficult to tell on inspection the 
exact limit of the process, so gradually may it shade into adjacent 
tissue. The floor is rough, covered by grayish or yellowish broken- 
down tissue, and small caseating tubercles may be present both 
here and in the margins. The ulcer may perforate the septum. 
The nasal secretion is increased, and is mucoid or mucopurulent in 
character, and more or less offensive. It may in some instances 
tend to crust, and a slight hemorrhage follow removal of the in- 
spissated layer. A peculiar feature of the disease is its remarkable 
freedom from pain. There is little or no tendency to heal, and 
should healing take place, the morbid process sooner or later 
recurs. The form characterized by tubercular neoplasms, as a 
rule, has a different nasal site, occurring almost wholly on the 
turbinated bodies. The tumors vary in size and give rise to more 
or less marked obstructive symptoms. Their shape is usually 
irregularly rounded ; they may be smooth, granular, or nodular, 
have a broad base, and the overlying tissue in varying stages of 
hyperemia ranges in color from a gray or pale pink to dark red, 
or, later becomes yellowish or whitish. A peculiar pallor of the 
mucous membrane has been noted in some cases. They may bleed 
on slight irritation — in fact, scanty hemorrhages do, not infre- 
quently, occur. At first they are hard and firm to the touch, but 
later they become soft in the center with a hard periphery, and 
finally complete softening, rupture, and discharge occur, and a 
tubercular ulcer identical with that first described is formed. The 
nasal secretion is moderately increased and, after ulceration, 
assumes the characteristics already given. Pain is absent, and 
practically the only annoyance is the nasal obstruction, which may 
amount in some cases to complete occlusion. They exhibit the 
same tendency to resist reparative processes. If the tumor be 



NASAL TUBERCULOSIS. 169 

removed, its site heals with extreme slowness and the growth 
tends to recur. In one or two reported cases the condition has 
taken the form of luxuriant granulations completely filling the 
nasal space. Both forms may occur at the same time, and the 
disease may be unilateral or involve both spaces. 

Diagnosis.— The ultimate test is the identification of the 
specific bacillus in the discharge or in the growth, and in some 
cases may be the only sure diagnostic point. Tubercular symp- 
toms elsewhere, as in the mouth, the tongue, the pharynx, the 
larynx, or the lungs, form highly important diagnostic aids, as 
does also a history of hereditary taint, Syphilitic lesions may be 
eliminated by the history, general symptoms, and by their behavior 
to antisvphilitic measures in cases otherwise doubtful. It must 
not be forgotten that the two conditions may coexist. Malignant 
growths run a more rapid course ; most of them are painful, and 
they are more or less influenced by age. 

Prognosis. — The outlook as to cure is extremely unfavorable. 
It is considered, however, to be in itself the least fatal of all the 
tubercular manifestations, and may run a sIoav chronic course 
extending over many years. With serious involvement in other 
regions of the respiratory tract, it is a factor by no means insig- 
nificant in hastening a fatal termination. It undoubtedly exercises 
a predisposing influence upon many of the infectious and con- 
stitutional diseases. 

Complications. — The slow course of the disease, the increas- 
ing area of ulceration, and the decreased resistance of the mem- 
brane render it liable to be complicated by almost the whole list 
of diseases due to local action of specific germs. 

Treatment. — If there be any discharge from the nose, due to 
the tubercular involvement, the mucous membrane is to be kept 
clean by the daily use of Dobell's solution. Tubercular neoplasms 
should be removed with the scissors or snare, and their sites 
touched with chromic or lactic acid. Ulcerations should be 
curetted and thoroughly treated with lactic acid in strength of not 
less than 50 per cent. If removal of the local lesion is attempted, 
it must be thorough and complete, otherwise the attempted eradi- 
cation would serve only to open up the lymphatic system and pro- 
mote rapid dissemination of the infection. If pain be present — 
which is the exception rather than the rule — application of men- 
thol in olive oil (1 : 20) may be made to the sensitive areas. 
Guaiacol in full strength, applied to the ulcerated areas, affects the 
disease favorably, and it obtunds the pain. The general system 
should be carefully reinforced to aid against the local ravages of 
the disease, by the administration of cod-liver oil or the hypophos- 
phites. The patient should be sent to a locality where climatic 
conditions suitable for improvement in the general health can be 
found. 



170 DISEASES OF THE ANTERIOR NASAL CAVITIES. 



LUPUS. 

Lupus is a chronic inflammatory disease of the nasal mucous 
membrane, characterized by the development of small elevated 
nodules which tend to coalesce and spread, and usually proceed to 
ulceration. Absorption may, however, take place, leading to a 
subsequent atrophy of the affected parts. 

We are considering the disease only in its intranasal manifes- 
tations, believing that lupus of the nasal integument belongs by 
right to the province of the dermatologist. 

Etiology. — There has been a growing tendency to regard 
lupus as a tubercular disease, and at present this is the generally, 
and we believe rightly, accepted view of its character. Naturally 
we would expect that the majority of cases would occur in those 
with a tubercular history, and in reality it is the case. The dis- 
ease is not common and may rarely be primary in the nasal mem- 
brane, but is usually a secondary development from lupus of the 
facial integument. Females seem more prone than males to the 
disease, and those living in the country are said to acquire it 
oftener than those living in towns. The average age at which the 
affection is seen is given as thirty-six, but no age is exempt, 
and cases have occurred in very young subjects. Abrasions and 
atonic states of the mucous membrane, such, for example, as those 
accompanying prolonged catarrhal inflammations, are undoubt- 
edly predisposing factors. The disease itself does not seem to be 
hereditary. 

Pathology. — The morbid process usually begins, when pri- 
mary, on the anterior part of the septum, just within the nostrils, 
and from there spreads, usually down over the floor and across to 
the turbinated bodies. The lateral cartilages of the nose are rarely 
attacked, unless by the inward spread of the cutaneous form, and it 
is doubtful if the bony structures are ever directly involved. The 
disease seems not to be transmitted to any notable distance by the 
lymphatics, though gland-involvement, according to Hamilton, does 
sometimes occur. The disease begins by the formation of a small 
nodule or nodules, which increase in number and finally coalesce 
to form a slightly elevated area with nodular surface. These 
nodules are small and hard, distinctly outlined, and the overlying 
tissue is hyperemic and traversed by distorted and congested 
blood-vessels. Later the growths may become paler in hue, 
and if ulceration has begun they, as well as the ulcerating 
surface, may become partially covered by pale- brownish flakes 
of inspissated secretion. Degenerative changes, the result of 
obliterated blood-supply, occur in the nodules, and ulceration, 
with discharge of the necrosed and liquefied tissue, converts 
the area into an ulcer which is round or ovoid, with an ele- 
vated and indurated margin, and not infrequently with a shallow 



LUPUS. 



171 



cup-shaped excavation. The process may cause perforation of 
the cartilaginous septum. A peculiarity of the necrosis is the ser- 
piginous manner in which it spreads, the lesion advancing by new 
nodular formations in one margin, which ulcerate and coalesce 
with the exposed area, while beyond it, at another point on the 
periphery, healing by the formation of a bluish cicatrix is in 
progress. The process, as has been mentioned, may extend down 
over the nasal floor and involve the turbinates, especially the 
middle, though the bone is not attacked as is the cartilage. The 
morbid histology displays little or nothing to differentiate it from 




Atresia of nostrils. 



the tubercular lesion. A fully developed nodule shows the cen- 
tral giant cell, the immense numbers of small cells, and the periph- 
eral epithelioid cells. An important feature of lupus is the pres- 
ence of small numbers of tubercle bacilli. The vascular supply 
has the same pressure-influences upon the lesion, and, finally, 
obliteration occurs. There is more or less evidence of inflamma- 
tion in the adjacent tissue. Later, areas of mucoid change and 
of fatty degeneration are present, and, finally, ulceration takes 
place. The lower parts of the mass, as a rule, show marked 
cellular fatty-degeneration absorption. It sometimes happens that 
the disease, instead of following the ulcerative course described, 
reaches its nodular development, undergoes degenerative changes, 
and is finally absorbed instead of being discharged, leaving behind 



172 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

it a cicatrix of fibrous tissue which subsequently leads to atrophic 
change. In ulcerations due to syphilis, tuberculosis, and lupus, 
where the disease is arrested, peculiar and almost characteristic 
scar-formation results. The peculiar bluish-white scar following 
ulceration due to lupus was illustrated in a patient observed in 
my clinic at the Jefferson Medical College Hospital, a young 
woman twenty-three years of age (see Fig. 63), in which the 
disease had been arrested and cured. The ulceration had involved 
the mucous membrane of both nasal orifices and extended out on 
the surface of the skin. These surfaces, coming together, had 
united and completely occluded both nostrils, so that the patient 
was unable to breathe through the nose. 

Symptoms. — The disease may be confined to one cavity or it 
may attack both. The most marked symptom is the occlusion of 
the nasal space or spaces by the nodular growth. In many of the 
cases inspection of the deeper parts of the nose may be impossible 
and the middle turbinates may be completely obscured. There is 
but little discharge, w T hich, at first clear, becomes thicker as ulcera- 
tion proceeds, and may become somewhat fetid, if retained long 
enough in the cavity for putrefaction to take place. The lesion 
has a marked tendency to crust, forming small scales or scabs, 
grayish or dark in color, which are more or less tenacious, and 
may cause a slight oozing of blood on detachment. On inspection, 
if this is possible, the small characteristic nodules, less regular in 
outline, perhaps, than in cutaneous lupus, may be seen, located 
usually on the septum. They are hard at first to the probe, but as 
they soften, the instrument can be easily pushed into their sub- 
stance and even through the cartilage, causing slight hemorrhage. 
The growths are painful, as a rule, to the touch, though their 
presence and growth give rise to little pain. If they go on to 
ulceration, the characteristic appearances already described are 
present, and the serpiginous method of spreading is to be observed. 
The advance is usually of slow progress, and the occurrence of 
septal perforation has been mentioned. The external appearance 
of the nose is altered, becoming pale and rigid, and having a 
pinched and shrunken look as cicatrization advances. Or if the 
same process occurs simultaneously in the skin of the nose, the 
latter organ may present extensive ulcerations and erosions, lead- 
ing to large areas of tissue-loss, horrible deformity from the result- 
ant cicatrices, or even to stenosis. Itching may be present. The 
form of the disease with ulceration is known usually as lupus ex- 
edens, while that in which ulceration does not take place is termed 
non-exedens. The latter form is identical with the former in de- 
velopment and symptoms up to the stage of completion of nodular 
formations. Instead of this going on to ulceration, however, ab- 
sorption of the softened material takes place, and inspection shows 
the formation of bluish-white cicatrices at the site of the process, 



LUPUS. 173 

which subsequently contract and cause atrophy of the affected 
area. The process does not spread as does lupus exedens. Con- 
stitutional impairment in either case is not marked. 

Diagnosis. — The diagnosis is usually easy. The history of 
the patient, the coexistence usually of the cutaneous form, the slow 
course, nodular growth, and serpiginous spread in the exedens, or 
the cicatrization in the non-exedens, make the diagnosis evident. 
Syphilis is differentiated by its history, by its intermittent periods, 
by the presence of bone-involvement, and by response to specific 
treatment. Malignant neoplasms are usually more rapid in growth, 
are painful, and occur, as a rule, later in life. Fibroma is firmer 
and not easily torn. Mucous polyps are smooth, soft, and trans- 
lucent, and usually pedunculated. The nodules of nasal tuber- 
culosis are not irritable to the touch, and the ulceration does not 
spread in the same manner nor exhibit, save rarely, reparative 
tendencies. 

Prognosis. — The prognosis is grave as to cure of the disease 
or prevention of deformity ; not, however, as regards life. The 
disease runs a slow chronic course, which is more amenable to 
treatment than lupus of the skin, and may in a few cases be 
checked. A few cases of spontaneous recovery are on record. 

Complications. — Erysipelas has been reported as occurring 
during the course of the disease. Any of the infectious conditions 
are liable to be contracted through the ulcerated surface. 

Treatment. — Local. — The lesions of lupus of the nasal cavity 
should be thoroughly and carefully extirpated. This can be done 
after cocainization (1) by removing the crusts to see the full extent 
of the invading process, (2) by using the curet to remove all the 
visibly affected tissue and a little of the healthy tissue beyond, (3) 
by the application of 60 per cent, lactic acid to the denuded area. 
The more thoroughly this is done the less liable is there to be 
recurrence of the growth. The field of operation should be kept 
scrupulously clean by flushing it daily with an alkaline antiseptic 
solution such as : 

1^. Sodii biboratis, 
Sodii bicarbonatis, 

Sodii chloratis, ad gr. xv (.9) ; 

Acidi carbolici, gtt. iv (.24) ; 

Aquae, flsj (30.) ; 

followed by thoroughly covering the site of the lesion with — 

R. Pyoktanin, gr. xx-lx (1.2-3.6) ; 

Zinci stearatis, SJ (30.). 

Constitutional. — Cod-liver oil during the cold weather, the 
hypophosphites in summer, besides iron and strychnin are to be 



174 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

administered. Equable climate with an outdoor life and a gen- 
erous dietary are to be prescribed. 

GLANDERS. 

Definition. — A highly contagious disease of horses, rarely 
transmitted to man, but, when so existing, is characterized by 
severe constitutional symptoms, and by formation, in the sub- 
mucosa of the infected mucous membranes, of granulation-tumors 
which run a rapid course to ulceration, and are accompanied by an 
offensive discharge. The nasal mucosa is usually primarily in- 
volved. The disease is rapid in progress, extremely fatal, and 
occurs in both acute and chronic manifestations. This definition 
considers only the relation of the disease to the respiratory tract, 
the consideration of its other lesions being scarcely within the 
scope of the present work. 

Synonyms. — Equinia; Maliasmus ; Malleus; Malleus hu- 
midus. 

Etiology. — The specific cause of glanders was discovered by 
Loffler in 1882, and is known as the Bacillus mallei, or bacillus 
of glanders. It is a short, thick bacillus with rounded ends, non- 
motile and non-flagellated. Spore-formation has not been de- 
monstrated, but the germ itself possesses considerable vitality 
under favorable conditions. The malady is primarily a disease of 
the horse, whence, usually, it is communicated to man, though 
cases are reported of its transmission from one human being to 
another. Naturally, it is most often encountered in those whose 
occupation brings them in contact with horses. It is highly prob- 
able that an abrasion or wound of the cutaneous or mucous surfaces 
is necessary for inoculation, though some cases seem to indicate 
that lodgement of the germ upon an intact surface may be followed 
by development of the disease. Infection has been traced to the 
handling of cloths used on infected animals, drinking from their 
watering buckets, and to contact with infected secretion, either 
from sneezing or by a bite. It has followed the common use of a 
handkerchief. The disease has developed in animals fed on infected 
horse-meat. It is not unlikely that the air of stables occupied by 
infected animals may contain the dried but still virulent germ 
suspended in it. In some cases it is extremely difficult to obtain 
a satisfactory history of the source of infection. 

Pathology. — The nasal lesions of glanders consist in the de- 
velopment of numerous scattered or closely grouped granulation- 
tumors in the submucosa of the infected membrane. The bacilli, 
having gained entrance to the lymph-structures of the membrane, 
spread, and by their lodgement determine the site of the new- 
formations. At these sites there is produced irritation from the 
presence or products of the germ ; there is a proliferation of leu- 
kocytes forming lymphoid cells, and of connective-tissue cells 



GLANDERS.- 175 

forming epithelioid cells, and gradually an increasing mass of these 
and the bacilli is formed. As growth goes on, there is interference 
with nutrition, and, because of this, with perhaps additional action 
of the bacilli, beginning at the center — that being the point 
farthest from nutrition — the mass undergoes liquefaction-necrosis ; 
there is a thinning followed rapidly by rupture of the intervening 
tissue, and a discharge of the puruloid material upon the surface 
of the membrane. As a result of this process, there are formed 
numbers of what are practically small abscesses or ulcers, varying 
with the extent of the lesion. If a section be made of the tumor 
and it be examined microscopically, it will be found to consist 
almost wholly of epithelioid and lymphoid cells, with numerous 
bacilli scattered between them, and a considerable amount of 
fibrous structure. In the acute form also there will be evidence 
of acute inflammation in the number of multinuclear leukocytes 
infiltrated into the adjoining tissue. In the chronic cases the 
necrotic process frequently involves the deeper structures, and 
complete disintegration of parts of the bony structure have been 
reported. Gangrene of the softer tissues may occur. 

Symptoms. — The chronic form in man is not so frequent, nor 
is it so rapid, as the acute form, but, since the acute usually forms 
the terminative stage if present, we shall reverse the usual order 
and consider the chronic first. In both cases the constitutional 
symptoms are so essential that a brief description of the disease as 
a whole is necessary. In the chronic form the membrane becomes 
swollen, may be painful, though it frequently is not, and is covered 
with dirty crusty scabs. There is more or less of a peculiar, vis- 
cid, mucopurulent discharge of marked fetor, which, as ulceration 
progresses, becomes more serous. Cutaneous involvement with 
either the development, maturation, and discharge of subcutaneous 
nodules, or with the more superficial formation of bullae, is seen. 
There are extensive lymphadenitis and lymphangitis, and the wide 
distribution of the suppurative process causes irregular fever. 
Destruction of the deeper structures occurs, as well as necrosis of 
bone and cartilage, with discharge of necrosed material and gan- 
grene of the superjacent or adjacent surfaces. If the acute form 
does not terminate the disease rapidly, the patient goes on to ema- 
ciation, profuse sweating and colliquative diarrhea with accompany- 
ing exhaustion appears, and death eventuates from collapse. In 
the acute form, the disease is ushered in rapidly with all the symp- 
toms of an acute infection ; lassitude, rigors, pain of a rheumatic 
character in the trunk, back, limbs, and the joints, in addition to 
headache, dyspnea, irritation of the stomach with nausea and vomit- 
ing, and diarrhea follow. The site of infection becomes hot, red, and 
swollen, lymphangitis follows, and adjacent parts swell and redden. 
Small nodules appear in the submucosa, at first translucent, later 
darkening, and then turning a yellowish hue, and finally rupturing. 



176 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

There is a discharge of a thick, deep-yellow, often blood-streaked, 
offensive, semi-fluid material, possibly more from one nostril than 
the other. Ulceration follows, which shows but little tendency to 
heal. The cutaneous structures become similarly involved, the 
nodules form, go through the stages of papule and pustule, and prac- 
tically become abscesses. The lymphatics, especially of the neck, 
swell and become enlarged. The systemic impression is profound, 
the temperature and pulse are high, the tongue is dry and coated 
with a whitish fur. The disease progresses rapidly into a typhoid 
state ; there are wasting, weakness, and exhaustion from profuse 
sweats, nausea and vomiting and frequent diarrhea, and death 
soon supervenes. 

Diagnosis. — The ultimate diagnostic test is the identification 
of the germ, either by staining or the more satisfactory test of in- 
oculation in susceptible animals. Reaction to mallein offers a pre- 
sumptive proof. The physician, as a rule, because of the rarity of 
the affection, is apt in a given case to think of glanders last of all 
the possible conditions, or overlook it altogether. A history of in- 
oculation or exposure must be sought for diligently, full character- 
istic symptoms, if possible, elucidated, and the practitioner should 
base his diagnosis from a broad comprehensive view, rather than 
the careful investigation of any set of manifestations. Venereal 
disease of the respiratory tract may be separated by the lesser 
constitutional exhibition and the reaction to potassium iodid. 
It may simulate typhoid, but lacks the rose spots. Pyemia is, 
perhaps, the most likely condition for which it may be mistaken, 
and may, as it rightfully should, force a bacterial examination. 
In certain stages it is difficult to differentiate from malignant 
growths. 

Prognosis. — The outlook in either the acute or chronic form 
is extremely grave. Several cases of the acute have been reported 
as recovering, and these usually have had little accompanying 
eruption. Death, however, usually occurs after a variable length 
of time — a few hours to several days. The chronic form with 
skin-manifestations is usually fatal. BroardePs dictum — " so long 
as the nose is not affected, there is still room for hope " — is to be 
considered in making the prognosis. A few cases run a course of 
repeated series of abscesses and recover. The large proportion of 
cases die in from six to eight months. 

Complication. — A subacute pneumonia is reported as having 
occurred in conjunction with the disease. 

Treatment. — The treatment of the nasal manifestations of 
glanders should consist in the opening and curetting of abscesses, 
in the curetting and cauterizing of the ulcers, and the thorough 
removal of any suspicious growths. For the offensive discharge 
Elliotson recommends the use of a douche three times a day con- 
sisting of 2 grains of creosote to the pint of water. Carbolic acid 



LEPROSY. 177 

(1 : 60) may be applied on lint as a dressing for ulcerated areas 
(Mackenzie). In the light of the highly contagious nature of the 
disease, prophylactic measures should be insisted upon, and the 
most rigorous antisepsis preserved. 

Constitutional. — Iron, quinin, whiskey, and strychnin are to 
be employed in heroic dosage. Da Costa states that iodid of 
potassium has cured cases. When a positive bacteriological diag- 
nosis has been made, while the curative effect of mallem is still 
doubtful, it should be employed. 

LEPROSY. 

Definition. — Leprosy of the respiratory tract is a rare disease 
in this country, and occurs almost or quite exclusively as nasal, 
pharyngeal, or laryngeal complications of the general condition. 
The anesthetic variety is characterized by local anesthetic areas 
from neuritis of the connected nerve-supply and by subsequent 
trophoneurotic changes. The tubercular variety is distinguished 
by the formation in the submucosa of local masses of granulation- 
tissue, which undergo liquefaction-necrosis and ulceration, the 
ulcers exhibiting a varying tendency to heal by cicatrization. It 
is due to a specific germ. We are considering the disease only in 
its relation to the respiratory tract. 

Synonyms. — Elephantiasis Grsecorum ; Lepra. 

Etiology. — It is now generally considered that leprosy is due 
to a specific germ, designated the Bacillus leprce. This germ re- 
sembles the bacillus of tuberculosis morphologically and in its 
behavior to certain differentiating stains. It is non-motile, possesses 
no flagella, and reproduces apparently both by spore-formation 
and fission. The disease is most common in the Sandwich Islands, 
China, and India, and the majority of cases occur between the 
ages of fifteen and thirty years. Leprosy is feebly contagious, 
but the exact modes of inoculation are not clearly understood, 
largely on account of the non-existence of a definite lesion at the 
point of inoculation. It has apparently been contracted through 
sexual intercourse, by inoculation during vaccination, and seems, 
in short, to be as varied in the manner. of transmission as is syph- 
ilis. Hereditary transmission is a common feature in the history. 

Pathology. — Two forms of the disease are recognized, the anes- 
thetic and the tubercular, and both may exist synchronously in the 
same patient. In the anesthetic variety the lesions show changes 
in the nerves supplying the affected areas on the body, which, if 
examined microscopically, are seen to consist of a cellular infil- 
trate between the fibers of the nerve, with a subsequent organiza- 
tion and contraction of cicatricial tissue — in short, a chronic in- 
terstitial neuritis. Following loss of the nerve-influence atrophic 
changes occur, ulceration of anesthetic areas, wasting of muscle 

12 



178 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

and glands, with necrosis and discharge of bone. The lesion of 
the tubercular form is characteristic, and is the distinctive feature 
placing the disease among the infectious granulomata. At the 
sites of germ-invasion, the bacilli generate an inflammation which 
is followed by infiltration and proliferation of all the cellular ele- 
ments and the formation of a granulation-tumor. If the morbid 
histology of this growth be studied, it will be found to be much 
like the growths of the others in this class. There is a large 
number of small round epithelioid and lymphoid cells, and not 
a few giant cells. Certain of the giant cells show a remark- 
able tendency to the formation of vacuoles at the expense of 
their protoplasm, practically becoming sacs filled with the bacilli. 
The germ is also seen in great numbers in the lymph-spaces, 
by which channels, excepting in a few cases, it is believed to 
spread. The fibrous tissue is increased in amount and is largely 
inflammatory in character. If the section be made at a later 
stage, there will be evidences of a central liquefaction-necrosis in 
progress, with encroachment toward the surface, and, if the section 
be made after rupture and escape of the liquefied tissue, the his- 
tological picture of a suppurative ulcer is presented. In both 
varieties the pathological alterations differ only from the cutaneous 
lesions as to site ; the processes are identical. 

Symptoms. — In most cases, with perhaps very few exceptions, 
the condition is secondary to the cutaneous and systemic invasion 
of the disease, and its appearance in the respiratory tract is there- 
fore anticipated. P. A. Morrow, after a visit to Hawaii, states 
that usually the first manifestations of the disease are in the phar- 
ynx and upper air-passages. The anesthetic form is said not to make 
its appearance until the disease is at least of five years' standing. 
There are areas of the membrane with complete anesthesia, both 
in the nasal spaces and the pharynx ; the soft palate is insensitive, 
and motor paralysis of the larynx may occur. Ulceration follows, 
and later there is an absorption of the nasal bones. In the tuber- 
cular form, the nodules follow precisely the same developmental 
course as in the skin. During the first or erythematous stage, the 
mucous membrane reddens, becomes hyperemic, and slight epis- 
taxis may occur at intervals. Later, the membrane pales and 
becomes thickened, especially in the lower pharynx. It appears 
as though covered with a thin transparent coating, and its sensi- 
bility both to smell and general impressions is notably decreased. 
The swelling may cause interference with respiration, and, if 
occurring at the same time in the pharynx and larynx, there are 
early fatigue, and dryness of the throat in speaking, and the voice 
becomes progressively nasal, then shrill, and finally ends in 
aphonia. Following this, the second stage comprises the develop- 
ment in these inflamed areas of numerous small nodular masses, 
which may remain discrete or coalesce. Their presence causes a 



NASAL ACTINOMYCOSIS. 179 

pressure-atrophy of the glandular elements in the overlying struct- 
ure, and its surface becomes smooth, tense, and glistening. The 
evidences of varying respiratory stenosis continue. This stage 
may show great variation in duration, running a course of a few 
weeks to several months, and in some cases may be the termina- 
tive period. In most cases, however, it is followed by a third and 
final stage. The nodule softens, opens, discharges, and a small 
ulcer forms. Pyogenic infection is superadded, the discharge be- 
comes thicker, yellowish or brownish, has a tendency to crust, and 
is usually offensive. The ulceration increases in extent and depth, 
and changes not unlike those of tertiary syphilis are produced in 
the facial appearance of the patient. The turbinates atrophy and 
finally disintegrate ; the septum is perforated by the ulceration, and 
not infrequently also the hard palate ; the cartilaginous and bony 
framework of the nose is weakened, and the nose flattens and col- 
lapses. The soft palate may be quite destroyed. Bands of cica- 
tricial tissue may form, and by their contraction markedly distort 
the weakening structures in which they occur. 

Diagnosis. — The diagnosis is generally easy, because of the 
usually antecedent condition displayed on the bodily surface. Ter- 
tiary syphilis may be differentiated by its history and its reaction 
to specific medication. 

Prognosis. — The prognosis for the nasal involvement is 
essentially that of the general disease, and this is almost always 
ended sooner or later by death from exhaustion. The respiratory 
involvement increases the gravity of the prognosis by its added 
liability to sudden suffocation from edema or a lower stenosis. 
The anesthetic variety runs a course of from fifteen to twenty 
years and the tubercular of from eight to ten years. Occasionally 
spontaneous recoveries have taken place, and recorded cures are 
not infrequent. 

Treatment. — No treatment has been found that will cure 
leprosy. The internal administration of chaulmugra oil, 5 to 60 
drops daily, according to Ingals, has apparently benefited some 
cases. Inunction of an ointment prepared from the same oil, 
with 5 or 6 parts of lard, should be used at the same time. 

NASAL ACTINOMYCOSIS. 

There seems to be no authentically reported case of this mem- 
ber of the infectious granulomata occurring in the nasal spaces. 
There is evidently no reason why infection should not, under 
favorable circumstances, take place, since inoculation with the 
specific organism is as surely followed by development of the dis- 
ease as it is in the case of the other members of the group. That 
it has not occurred more frequently is, perhaps, due to its com- 
parative rarity in the human race and to the fact that it occurs 



180 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

usually in the mouth, pharynx, alimentary or respiratory tract 
below that level, as a result of metastasis or of the ingestion of 
infected food. It is by no means improbable, however, that cases 
have occurred in which the diagnosis of tuberculosis, or more 
likely of malignant growth such as sarcoma, has erroneously been 
made, and certainly the clinical history and physical appearances 
of the disease have much to extenuate such an error. We shall 
consider the features of the disease under its pharyngeal appear- 
ance, and refer the reader to that article, on page 600. 

RHINOSCLEROMA. 

Definition. — Rhinoscleroma is an extremely rare disease of 
the nose and, by extension, of the upper respiratory tract. It is 
characterized by the formation in the submucosa of the mucous 
membrane or the deeper layer of the cutaneous structure of firm, 
hard, nodular tissue, which shows marked tendency to lateral 
extension. The disease is painless, is unaccompanied by discharge, 
and rarely, if ever, progresses to ulceration. There is no con- 
stitutional involvement, and the local condition is remarkable for 
the extreme slowness of its course. It is believed to be due to a 
specific organism. 

Etiology. — The weight of present evidence regards the dis- 
ease as due to a specific germ — a short rod with rounded ends and 
usually capsulated, known as the bacillus of rhinoscleroma. As 
to the manner of inoculation, there is nothing definitely known. 
There are apparently no predisposing influences ; sex, constitutional 
diseases, personal habits and occupations seeming to bear no rela- 
tion to its occurrence. The cases reported show ages ranging from 
fourteen to forty-five years, and the greatest number as having 
occurred in Southeastern Europe. 

Pathology. — The lesion of rhinoscleroma consists patholog- 
ically in a round-celled infiltrate into the corium and papillae if 
occurring in the skin, or into the submucosa if occurring in mucous 
membranes. Histologically, the structure is composed of con- 
siderable fibrous tissue and an abundance of small round cells. A 
peculiarity of the lesion is the presence of certain large spherical 
hyaline cells with a protoplasmic reticulum containing one or more 
nuclei, smaller translucent hyaline particles, and the bacilli already 
mentioned ; or the smaller hyaline granules and the bacilli may be 
found in the interstitial lymph-channels in the fibrous structure. 
As the infiltrate increases, there intervenes more or less pressure- 
atrophy of the glandular elements. The round cells also undergo 
a change, becoming spindle-shaped, and finally forming fibrous tis- 
sue. It is of important pathological note that at no time during 
the history of the case will sections show any evidences of fatty or 
granular degeneration or evidences of breaking down. In one re- 



RHINOSCLEROMA. 181 

ported case cartilage-formation was in progress, and in another not 
only was cartilage present, bnt apparently ossification had begun. 

Symptoms. — The absence of constitutional symptoms and 
the slow development and spread of the local process are charac- 
teristic of the disease. It begins usually at the margin of the 
nostrils and contiguous part of the upper lip by the development 
of small nodules, which may be confluent or discrete. These firm, 
sharply defined, slightly elevated patches, which feel hard and 
smooth to the touch, are traversed by dilated blood-vessels, are 
hairless, and may or may not be somewhat shiny. The overlying 
tissue is natural in color or perhaps slightly darkened in hue. 
There is no discharge, no ulceration, and no pain, except a slight 
tenderness on pressure. The process tends more readily to follow 
the mucous membrane in its advance than the cutaneous surface, 
and spreads by extension of the infiltration laterally, or by 
coalescence of discrete nodules. In some cases it may take 
the form of a general diffuse infiltration without the forma- 
tion of nodules. The swelling gradually spreads through the 
nasal membrane, and may extend to the pharynx and to the 
larynx and trachea, giving rise to symptoms of obstructed 
respiration and phonation. The process may involve the skin of 
the lips, brow, and part of the alse ; cracks and fissures may occur 
at the junction of the latter with the facial integument. It may 
involve the septum, gums, and alveoli, and, in rare cases, the 
tongue, eyes, and ears may become implicated. The surfaces adjacent 
to the swelling show no edema nor evidences of inflammation ; the 
swelling itself presents clinically no evidences of inflammatory or 
degenerative change, and is in the majority of cases symmetrical 
in distribution. The nose, as a result of the disease, becomes thick- 
ened, acquires an unnatural stiffness, and causes nasal obstruction. 

Diagnosis. — The rarity of the disease in this country is a 
potent factor in obscuring diagnosis. Constant nasal localization, 
hardness of affected parts, with sharp outlines and absence of 
adjacent inflammatory phenomena, slow development and absence 
of pain, lack of constitutional symptoms or any evidence of retro- 
gressive change in the growth, stubborn resistance to treatment, 
and, lastly, demonstration of the germ form the correlated group of 
diagnostic points. Syphilis may be differentiated by the history, con- 
stitutional exhibitions, and reaction to antisyphilitic measures. Epi- 
thelioma may be separated by its bleeding, softness, ulceration, and 
more rapid spread. Keloid in many cases may differ symptomati- 
cally only in the absence of the associated germ of rhinoscleroma. 

Prognosis. — The disease seems intrinsically to have no effect 
upon the prolongation of life, but may become a very serious men- 
ace mechanically by occlusion of the larynx and trachea. The 
prognosis as to cure is most unfavorable ; no drugs modify the dis- 



182 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

ease, and complete extirpation of the diseased areas is in almost 
every case followed by a return of the growth. 

Complications. — The extension of the process to the pharynx 
and the involvement of the uvula with its subsequent atrophy, occa- 
sional attacks of aphonia and laryngeal spasm, and the increase of 
the growth to suffocation are the commonest of the complications. 

Treatment. — The treatment of rhinoscleroma is purely pallia- 
tive. Surgical interference is limited to the removal of sufficient 
tissue to relieve nasal obstruction. Internal medication, outside 
of the improvement of the patient's general condition, should con- 
sist in the administration of mercury and the iodids. 



CHAPTER VI. 
FURUNCULOSIS. 

Synonym. — Phlegmonous rhinitis. 

Definition. — The term furunculosis is applied to abscess- 
formation involving any part of the nose, while the term phleg- 
monous rhinitis is limited to abscesses involving the nasal mucous 
membrane, and is a rare condition. 

Etiology. — The condition usually follows an injury, and 
occurs most frequently on the septum and near the nasal orifice. 
The furuncle may be single or multiple. The inflammation may 
have its origin in a hair-follicle. In many individuals the attacks 
of boils frequently recur, and the cartilage is always involved. It 
most commonly affects the young or middle-aged, and is associated 
with blood-dyscrasia. Persons who are the subjects of chronic 
constipation are frequently attacked. It is often associated with 
infectious fevers. 

Pathology. — The pathology is the same as in any abscess- 
formation. 

Symptoms. — The symptoms consist in the characteristic 
phenomena, both clinical and microscopical, of any inflammatory 
process, with the swelling, throbbing, and tension characteristic of 
inflammation in unyielding structures. 

Treatment. — If pus has formed, the abscess should be freely 
opened and thoroughly cleansed with an antiseptic solution. Com- 
presses may be applied early, either hot or cold. For relief of the 
pain a solution of chloral hydrate, 1 dram to 1 ounce each of 
glycerin and water, may be used locally. If seen early, before pus 
has begun to form, applications of 50 per cent, ichthyol solution 
may arrest its development. In opening the abscess the puncture 
should be made within the nostril, so as to avoid any external scar. 
Frequently the pus forms within the septum, separating the carti- 
lage. Care should be taken in attempting to puncture, as the 
cartilage is firm, requiring a sharp bistoury and deep incision. 

183 



CHAPTEK VII. 

INFLAMMATORY DISEASES OF THE ANTERIOR NASAL 

CAVITIES. 

Ulcers, non-infected. 

a. Simple. 

1. Catarrhal. 

2. Herpetic. 

3. Eczematous. 

4. Due to foreign bodies. 

5. Neuroparalytic. 

6. Scorbutic. 

7. Diabetic. 

8. Varicose. 

9. Chemic. 

b. Compound — Malignant. 

Ulcers, infected. 

1. Tubercular (lupoid). 

2. Syphilitic. 

3. Leprous. 

4. Glanders. 

5. Diphtheritic. 

6. In measles. 

7. In rheumatism. 

8. In scarlet fever. 

9. In small-pox. 

10. In typhoid fever. 

11. In typhus fever. 



ULCERS. 

It has seemed best to consider thus collectively the various 
forms of ulceration occurring in the mucous membrane of the 
nose. 

An ulcer of the mucous membrane is a superficial necrosis 
which must extend through the basement membrane, and may or 
may not involve the submucosa. 

In diseases in which there is ulceration or fetid discharge, the 
parts should always be carefully inspected before the removal of 
the secretion, as its character will aid materially in the diagnosis. 

The numerous causes of necrosis will be mentioned under the 
different forms of ulceration in which they occur. 

184 



ULCERS. 185 

XOX-IXFECTED ULCERS. 
(a) SIMPLE ULCERS. 

Catarrhal Ulcers. — Occasionally, in nasal conditions in 
which abundant discharge is a prominent symptom, simple ulcer- 
ated areas are seen near the nasal orifices on points of prominence, 
such as exostoses of the septum, or points of contact of enlarged 
turbinates with the septum, or any location where secretions may 
lodge. These denuded areas are painful and sensitive and give 
rise to considerable annoyance to the patient. 

They should be cleansed with hydrogen peroxid and cinnamon 
water and covered with a protective stimulant, such as the com- 
pound tincture of benzoin and boroglycerid (50 per cent.) in equal 
parts. The removal of the cause of irritation, together with the 
above procedure, will generally prove curative. 

Stimulation may be applied by using chromic acid (10 per cent.) 
on a cotton-covered probe. Equally good results may be obtained, 
especially if the ulcer is sluggish, by the local application of a 3 
per cent, formalin solution. 

Herpetic Ulcers. — The mucous membrane of the nostrils 
may be attacked by herpes. The disease appears as groups of 
vesicles, each about the size of a millet seed or a split pea, and is 
accompanied by local rise of temperature, thirst, rapid pulse, and 
local irritation. In a few days the vesicles dry up into thin scabs, 
which are sometimes confluent, and not generally surrounded by 
an inflammatory zone. 

Treatment of the condition should consist in giving calomel, 
grain jr, bicarbonate of soda, grain 1, every hour until six doses 
are taken, followed in six hours by a Seidlitz powder. The crusts 
should be softened and removed with hydrogen peroxid and cinna- 
mon water in equal parts, and a 3 per cent, chlorid-of-zinc solu- 
tion mopped over the surface. 

Edematous Ulcers. — The eczematous form of nasal ulcer 
is seen most frequently in young children who have the eczema- 
tous eruption on the upper lip and cheeks. It is also observed 
following the exanthemata, especially measles. Occasionally the 
lesion may be found in older persons having the eczematous 
diathesis. 

In children, overindulgence in improper food, especially sweets, 
or irritation in the lower bowel due to the presence of ascarides 
are generally the chief sources of disturbance. 

There is not, as a rule, pronounced odor from the discharge, 
which may or may not be copious. Crusts tough and dislodged 
with difficulty form at various points. The constant picking at 
the nose, due to the itching, is a continual source of irritation, and 
tends to prolong the affection. 



186 INFLAMMATORY DISEASES OF ANTERIOR NASAL CAVITIES. 

In adults there is, as a rule, excessive deposit of urates in the 
urine, a disinclination to take healthful exercise, with drowsiness 
after eating, and an habitually torpid condition of mind and body. 

Treatment. — The nostrils should be kept clean with the warm 
solution mentioned on page 135. Santonin in proper dosage should 
be given to children. Calomel and bicarbonate of soda in divided 
doses should precede and follow the administration of the san- 
tonin. This should be followed by granular effervescing phos- 
phate of soda in tablespoonful doses night and morning to stimu- 
late normal gland-secretion. Remove the crusts by softening with 
equal parts of hydrogen peroxid and cinnamon water, touch the 
denuded surface with nitrate of silver, 2 grains to the ounce of 
water, and cover the entire area involved with benzoated zinc-oxid 
ointment ; the benzoin should be double the amount given in the 
official preparation. In adults, correct any digestive disturbances 
present. Restrict the diet to plain meats and vegetables, and give 
tonics of iron, quinin, and strychnin, with lithiated waters. 

Ulcers Due to Foreign Bodies. — A foreign body, by its 
presence in the nostrils, may cause sufficient irritation to give rise 
to the formation of an ulcer which is of the simple catarrhal type, 
and, after the removal of the cause, should this not effect a cure, 
should be treated along the same lines. 

Neuroparalytic Ulcers. — Areas of ulceration in the nose 
have occurred, due to paresis or paralysis of the fifth pair of nerves. 
The mucosa is excoriated in patches of varying size, dry, sluggish, 
showing no tendency to heal. Hemorrhage from the affected side 
of the nose, and also loss of smell, have been reported as attendant 
symptoms. 

The treatment should consist in an attempt to re-establish 
proper trophic nerve-control by the use of electricity and strychnin 
nitrate, grain -^ to ^V? thrice daily. The ulcerated areas should 
be cleansed, stimulated, and protected. For this purpose, bovin- 
ine mopped on the surface acts, as it does in other trophic ulcera- 
tions, admirably. 

Scorbutic Ulcers. — Scorbutic ulcers are extremely rare, ex- 
cept when due to some accidental irritation in the course of scurvy, 
or when part of a general facial involvement by scorbutic ulcera- 
tion. There is an intolerable odor due to the fetid discharge. 
The edges of the ulcer are hard, thick, and shiny, and the surface, 
covered with clots due to the state of the blood, is fungoid and 
bleeding. The tendency to rapid enlargement of the lesion is 
marked. 

The treatment should consist in the administration of the 
juice of a lemon three times daily, a diet largely vegetable, and 
tonics. The ulcer should be kept clean, preferably by an acid 
wash consisting of dilute hydrochloric acid, 10 drops to the table- 
spoonful of water ; the fungoid masses ought to be cleared away 



ULCERS. 187 

with the scissors and forceps, and chromic acid (10 to 20 per cent.) 
applied to stimulate healing. 

Diabetic Ulcers. — Due to the general blood-dyscrasia in 
diabetes mellitus, there is often seen a low-grade inflammation of 
the upper respiratory tract. At various points of the mucous 
membrane there occur spots of ulceration, usually near the nasal 
orifice, and in most cases due to the patient picking and rubbing 
the nose to relieve the intolerable itching present in diabetic cases. 
These seem to bear in their extension and growth a direct ratio to 
the amount of sugar in the urine. The appearance of these ulcers 
is not especially characteristic, yet in connection with glycosuria 
and the low-grade rhinitis mentioned, the lesion should not be 
regarded as independent, but further cause for its existence sought, 
and the ulcer should be treated as a local manifestation of a sys- 
temic infection. 

Varicose Ulcers. — The engorgement of the venous plexuses, 
especially in the turbinal region of the nose, may be so great as 
to cause distention to the point of rupture and ulceration. It may 
also be found on the posterior border of the soft palate. Varicose 
ulcers are often associated with cyanotic conditions of the mucous 
membranes, and are in reality only local lesions due to systemic 
conditions. These ulcers are sluggish, slow to form, and slow to 
heal. They bleed easily and freely. In appearance, they are blu- 
ish-red, indolent, irregular in outline, shallow, and covered with 
a sanious, crusty discharge. 

Locally, the treatment should consist, after cleansing, in the 
application of stimulating astringents, such as 3 to 5 per cent, 
formalin solution or glycerite of tannin. Systemic treatment 
should be directed toward the relief of the underlying cause. 

Chemic Ulcers. — There is a variety of ulceration of the 
mucous membrane of the nose, nasopharynx, pharynx, soft 
palate, and buccal mucous membrane which is undoubtedly chem- 
ical in origin. It is observed in individuals of poor nutrition 
and lowered vitality, and is undoubtedly due to a chemical change 
in the secretion. In the cases which I have observed they have 
all been autoinfections due to excess of sulphocyanids in the sal- 
ivary and nasal secretions, and where the ulceration has occurred 
there was also associated an excessive alkaline reaction, and the 
alkalinity was due to ammonium salts. When the excessive alka- 
linity is due to the ammonium salts there is also a tendency 
to localized irritation of the mucous membrane surface ; so that 
I believe these ulcers to be of a chemical origin and that the 
pathological change which takes place in the tissue is really a coag- 
ulation necrosis with liquefaction, purely a chemical process. The 
ulcers vary in size and involve the epithelial layer and genetic 
layer of the basement membrane. There is very little induration, 
seldom, if ever, any bleeding, and the ulcer has a smooth surface 



188 INFLAMMATORY DISEASES OF ANTERIOR NASAL CAVITIES. 

with clear-cut edges. The treatment of this condition will entirely 
depend on the chemical change in the secretion, which is the etio- 
logical factor (see Nasal Neuroses, pages 205 and 206). 

(b) COMPOUND, MALIGNANT ULCERS. 

Any malignant growth occurring in the nose may be the site 
of a superimposed ulcerative process due to degeneration or press- 
ure. As the appearance of these ulcerated areas in the nose does 
not diifer essentially from that seen in other localities, the reader 
is referred for a complete description of the process to the chapter 
on Tumors (page 232). 

Infected Ulcers. 

Tubercular Ulcers (I/Upoid). — Tuberculosis of the nasal 
fossae is rare. The septum is the favorite site of the ulcerative 
process, but it may be found involving one of the turbinated 
bones. The simple tubercular ulcer has a whitish-gray surface. 
It is shallow, with irregular outline, and it is sometimes difficult 
to determine accurately where the disintegrating tubercular infec- 
tion ends and the healthy membrane begins. In the earlier stages, 
the miliary tubercles that have not broken down may be seen in 
the outlying parts of the ulcer. There is a tendency to bleeding, 
and the whitish-gray surface may be coated with crusts of dis- 
colored mucus. 

The treatment consists in the radical removal of the ulcer 
with the knife or cautery. The site should be treated with 50 
per cent, lactic acid and dusted with pyoktanin, or 40 grains to 
the ounce of stearate of zinc, or aristol by means of Gleitsmann's 
powder-blower. 

Anti tubercular treatment, addressed to the general systemic 
involvement, should be instituted. 

Syphilitic Ulcers. — The intranasal ulcerations of syphilitic 
origin include the chancre, the mucous patch, the superficial ulcer, 
and the deep ulcer Avith necrosis. 

Nasal chancre is exceedingly rare. It may be granular in 
appearance, or hard and cartilaginous with an ulcerating surface. 
The symptoms arising from the lesion are epistaxis, stenosis, and 
deformity if it be situated on the alse. 

No subjective symptoms are likely to be traceable to the mucous 
patch in the nose. It differs in no way from similar lesion occur- 
ring in the mouth, and needs no further description. 

The superficial ulcer, like the chancre, is not often met with in 
the nose. It occurs most frequently on the septum, but may be 
seen on the floor of the nose or on the surface of the turbinated 
bodies. The borders of the ulcer are fairly well defined, and the 
mucous membrane surrounding it is perfectly normal in appear^ 
ance. The edges are neither sharply cut nor depressed, and there 



ULCERS. . 189 

is no areola of redness. The surface of the ulcer is slightly 
depressed in the center and is covered with a coating of thick, 
stringy, yellowish-gray mucopus. On removal of this puroid 
material a grayish-pink color of the cleansed surface is seen. 
The lesion is feebly sensitive to the touch and bleeds easily. It 
has no marked tendency to extend, because its destructive activity 
is feeble. 

The deep ulcer of syphilis with bony necrosis arises directly 
from the gummy deposit, and occurs usually from ten to fifteen 
years after the primary lesion. The most frequent site of the 
process is on the septum, but if occurring on the turbinated bones, 
it is less amenable to treatment, pursues a more chronic course, 
and results in destruction of a greater amount of tissue rather by 
extending down into the underlying structure than by lateral 
spreading. As a rule, these ulcers do not extend beyond the 
posterior nares. The treatment of syphilis has been described 
(page 152), and needs no repetition. 

I/eprous Ulcers. — The mucous membrane of the nose is 
often involved in leprosy, either primarily or by extension from 
the alae nasi. 

When the leprous nodules ulcerate, the stench of the sanious 
watery discharge is intolerable. The cartilaginous septum may 
be perforated and, with the alse nasi, may be destroyed by extreme 
ulceration. Inspection of the nose may show a diffuse thicken- 
ing rather than a tubercular appearance of the turbinated bodies, 
followed by ulceration and fetid discharge. Epistaxis may be the 
first symptom noted by the patient. 

The diagnosis and treatment of the condition have been 
mentioned under Nasal Leprosy (page 179). 

Ulceration in Glanders. — A few days after the general symp- 
toms of glanders — which are chills, rheumatic pains in the limbs, 
fever and headache — there flows from the nostrils a glairy, thick, 
fetid discharge of a deep-yellow color streaked with blood, which 
may be greater from one nostril than the other. This discharge is 
due to the ulceration and breaking down of the lesions on the mucous 
membrane of the nose. The characteristic nodules of glanders in 
the nose are at first quite small, occurring singly or in groups. They 
rapidly increase in size. At first colorless, they become red, then 
gradually yellowish, and resemble pustules. A marked tendency 
to ulceration is present in these pustular lesions, and the resultant 
formation shows a foul sore with irregular edges, having little 
tendency to heal. The adjacent sinuses may be involved in the 
ulcerative process. The ulcers of glanders are not of themselves 
pathognomonic, but the diagnosis is aided by the rapid swelling of 
the adjacent structure, the extension of inflammation by the lym- 
phatics, and the rapid formation of swellings and phylazacious 
pustules around the original pustule. 



190 INFLAMMATORY DISEASES OF ANTERIOR NASAL CAVITIES. 

The treatment has been given under Nasal Glanders (p. 176). 

Diphtheritic Ulcers. — Diphtheritic involvement of the nasal 
chambers may be either primary, or secondary by extension. The 
common characteristics of all the lesions are the formation of 
the peculiar grayish membrane and an acrid, irritating, brown 
ichorous discharge. The diphtheritic ulceration does not differ 
from that occurring elsewhere in the body, except that in the 
primary form there is not that marked tendency to spread noticed 
if the membrane occurs elsewhere. 

Croupous or Fibrinous Ulceration — Chronic. — In certain 
cases, where there is a low-grade nutrition, there may be a chronic 
membranous condition involving the nasal mucosa. It has been 
described under Chronic Nasal Diphtheria, the diagnosis being 
based on the fact that the Klebs-Loffler bacilli have been found 
present. While this may be true, I do not believe that they are 
in any sense an etiologic factor, as I have frequently demonstrated 
their presence in the secretions collected in the nostril in atrophic 
rhinitis. There may be local ulceration in this condition which 
is due to the combined local infection and the low-grade systemic 
nutrition. The treatment is the same as given under Fibrino- 
plastic Rhinitis (page 101). 

Ulcers in Measles, Rheumatism, Scarlet Fever, 
Small-pox, Typhoid Fever, and Typhus Fever. — Ulcer- 
ation of the nasal mucosa, with implication of the bones and carti- 
lage to a greater or less extent, may occur in measles, rheumatism, 
scarlet fever, small-pox, typhoid fever, and typhus fever. Per- 
foration of the septum may result, and, in small-pox, obliteration 
of the nostrils has been reported as resulting from the union of 
the opposite raw surfaces of the outer and inner nasal walls when 
the crusts have come away. The ulcers are not in themselves 
peculiar or characteristic, and are mentioned that they may be 
guarded against by proper prophylactic treatment when such pro- 
dromata as nasal swelling, pain, and tenderness with discharge are 
noticed in any of the above-mentioned diseases. 

In scarlet fever the ulceration is generally due to a hemorrhagic 
inflammation, and amounts practically to the breaking down of 
the area of infarction. It may be infected either primarily or 
secondarily. 

In typhoid fever the ulceration is of more import, and is usually 
of greater severity. It is secondary to the disease, or rather a 
sequel, and is usually associated with inflammation of the carti- 
lage — a chondritis or perichondritis, followed by necrosis and ulcer- 
ation of the surface. The turbinal bones may be involved. The 
ulceration is always deep, involving the bony or cartilaginous 
framework, and occasionally followed by considerable loss of tis- 
sue and, possibly, caving deformity. 



CHAPTER VIII. 

NASAL NEUROSES. 

Neuroses of Olfaction. 
Parosmia. 
Hyperosmia. 
Anosmia. 

Reflex Nasal Neuroses. 

Respiratory Neuroses. 
Sneezing. 
Hydrorrhea. 

Hyperesthetic Rhinitis (Hay fever). 
Cough. 

Pharynx and mouth. 
Larynx. 
Asthma. 

Reflexes Outside of the Respiratory Tract. 
Ear. 
Eye. 

Migraine, Congestive Headache, Neuralgia. 
Chorea, Epilepsy, Vertigo, and Aprosexia. 
Stomach. 
Heart. 
Sexual Organs. 

Under the heading of Nasal Neuroses are to be included (1) 
Neuroses of olfaction, having to do with alteration in the sense of 
smell ; (2) The phenomena originating directly or indirectly in 
intranasal excitability, styled reflex. 

NEUROSES OF OLFACTION. 

The sense of smell, if normal, implies healthy olfactory bulbs, 
normal mucous membrane covering the superior turbinate, the 
upper half of the middle turbinate, and the upper three-fourths 
of the posterior part of the septum, and free ingress for the air 
laden with the odorous particles which excite the nerve-filaments. 
Alteration in any one of these factors may cause perversion or 
loss of olfaction. 

The neuroses of olfaction are Parosmia, Hyperosmia, and 
Anosmia. 

Parosmia. — By parosmia is meant a perversion of the sense 
of smell — a perception of imaginary odors superimposed on an 

191 



192 NASAL NEUROSES. 

otherwise healthy function. Pathological alteration of the olfac- 
tory nerve or bulb, brain-lesion, altered nasal secretion, or over- 
stimulation of the nerve-endings may be causal factors in the 
production of this condition. Subjective hallucinations of altered 
olfaction have been observed among the insane, and have been 
met with in epilepsy, hysteria, and syphilis. 

Hyperosmia. — Hyperosmia is an oversensitiveness to olfac- 
tory stimulus. Odors not ordinarily perceived by the normal 
sense of smell cause great annoyance, and unpleasant smells may 
persist for hours after the cause has been removed. Hyperacute- 
ness of olfaction may follow the impairment of nerve-force and 
the exaggeration of all impressions due to exhaustion or wasting 
disease, or it may be associated with hysteria, hypochondria, or 
neurasthenia. Hyperosmia has been found coexisting with sexual 
troubles in women, especially at the period of menstruation. 

Anosmia. — Anosmia, loss of smell, partial (dysosphresia) or 
complete, may be congenital or acquired. Any change in the 
nasal passages preventing free access of air to the upper nasal 
chambers may produce the condition. The most common cause 
of temporary loss of smell is the ordinary cold in the head. 

H. Zwaardemaker divides anosmia first, as to the manner in 
which stimuli fail to reach the olfactory center, either by occlu- 
sion of the anterior nasal passages to external odors, or by the 
failure of odors accompanying the acts of eating and drinking to 
gain access to the region, due to closure of the postnasal space or 
the choanse. Asymmetry of the nasal spaces, deflection of the 
septum, exostosis, enchondroma, hypertrophy, acute rhinitis, polyps, 
tumors of the nasopharynx, paralysis of the alee nasi, or absence 
of the external parts of the nose are causes producing either bilat- 
eral or unilateral loss of smell under this classification. A second 
classification of anosmia, by the same author, is into anosmia essen- 
tialis and anosmia intracranial, according as the nerve-endings 
of the olfactory cells, or nerves themselves, or the central olfac- 
tory apparatus in the brain is affected. 

Essential anosmia may be unilateral or bilateral, temporary or 
permanent. The condition may be due primarily to direct irrita- 
tion of gases, of strong or disagreeable odors, or of tobacco smoke 
constantly inhaled. Trauma of the olfactory nerves, or disease 
or trauma of the ethmoid bone has caused anosmia ; cocain appli- 
cations have produced it temporarily. Anosmia may be secondary 
to extension of a chronic inflammation from the lower part of the 
nose, to adenoids or polyps, to excessive or diminished nasal secre- 
tion. Morphin, atropin, and mercurial poisoning may cause it, as 
may ascending neuritis of the olfactory nerve. 

Anosmia intracranial may result 'primarily from injury to the 
olfactory bulb and tract, or by adjacent tumors affecting it, by 
degeneration, by congenital absence of the olfactory nerve, and by 



REFLEX NASAL NEUROSES. 193 

senile decay. Hemorrhage, abscess, tumors, necrotic and atrophic 
processes within the skull may secondarily produce loss of smell. 

The prognosis of loss of smell, in great measure, depends on 
the cause, and, although in cases of long-standing anosmia it would 
seem that atrophy would occur, cures have been reported after a 
period of forty years of disease of the function. 

The treatment is guided by the underlying causal factor. In 
any event, after the offending element has been removed, stimu- 
lation of the olfactory tract should be resorted to by the use of 
strychnin in insufflations of powder, commencing with -^ of a 
grain and gradually increasing the dose. 

REFLEX NASAL NEUROSES. 

By a reflex neurosis of the nose is meant a phenomenon hav- 
ing its origin in nasal excitability or nervous instability. For the 
production of a reflex act there are necessary an afferent sensory 
nerve, an efferent motor nerve, and between them a vague nervous 
mechanism called a reflex center. Owing to the introduction of 
the sympathetic system into this mechanism, the impulses as orig- 
inally sent from the periphery or the nerve-centers may be altered 
and modified — e. g., an impulse started as purely motor may 
arrive at its destination as vasomotor. 

An almost limitless number of pathological reflex manifesta- 
tions have been attributed to nasal origination, yet it would be 
advisable, before such a cause is definitely assigned, to investigate 
carefully whether, for its causation, the supposed nasal reflex be 
not entirely independent of any nasal condition, but coexistent and 
not causal, dependent on lesion elsewhere. The condition in the 
nose which implicates it in any of these reflex acts as a point of 
origin for the reflex has been the subject of much discussion. 
Whether it be due to engorgement of the erectile nasal tissue, to 
irritation caused by intranasal or extranasal agents, or to vaso- 
motor disturbance, or a combination of all of them, is not accu- 
rately determined. 

The various reflex nasal neuroses have been divided into sen- 
sory, motor, trophic, and vasomotor. For convenience they may 
be classed as neuroses of the respiratory tract and neuroses affect- 
ing other parts of the body. 

Respiratory Neuroses. 

Under the heading of Respiratory Neuroses are to be considered 
reflex manifestations occurring in the nose, nasopharynx, pharynx 
and mouth, larynx and bronchi. 

Sneering. — Paroxysmal or spasmodic sneezing occurs in cases 
in which there is no discoverable alteration in the nasal mucosa, 

13 



194 NASAL NEUROSES. 

and may be explained by a highly irritable condition of the mem- 
brane, with a corresponding irritability of the vasomotor centers 
due to lowered vitality. 

Hydrorrhea. — Hydrorrhea (Idiopathic rhinorrhea), or dis- 
charge of watery fluid from the nose, has already been discussed 
under another classification (Nasal Hydrorrhea, page 141), and is 
only mentioned here as a possible means of accounting for the 
otherwise inexplicable cases. 

Hyperesthetic Rhinitis. — Definition. — A periodical in- 
flammatory condition of the nasal mucosa, characterized by the 
appearance at intervals, usually of a year, of a prolonged and 
severe coryza, sometimes accompanied by asthmatic symptoms. In 
addition to the catarrhal manifestations, the mucous membrane 
displays areas of extreme hyperesthesia, and the patient is usually 
of the neurotic type. It is due to the local action of an irritant, 
either from without — usually of botanical origin suspended in the 
atmosphere — or due to local irritation from some internal irritant, 
such as uric acid. The disease is comparatively rare after the 
fortieth year of life. 

Synonyms. — Autumnal catarrh ; Catarrhus sestivus ; Coryza 
vasomotoria periodica ; Hay asthma ; Hay fever ; Idiosyncratic 
coryza ; June cold ; Peach cold ; Periodical hyperesthetic rhinitis ; 
Pollen catarrh ; Pruritic rhinitis ; Rag-weed fever ; Rhinitis 
hyperesthetica ; Pose catarrh ; Pose cold ; Pose fever ; Summer 
catarrh ; Pye fever ; Horse fever ; Lithemic rhinitis. 

Etiology. — This affection, if we are to place any reliance on 
medical literature, has been known to physicians for some cen- 
turies. Not, however, until the observations of Bostock in 1819 
does it seem to have been the subject of any serious attention, or 
to have been regarded as anything more than a severe type of 
rhinitis. Since then it has rightly claimed a more prominent 
place in the attention of both the general practitioner and the 
specialist, and has been the thesis of numerous theories and the 
subject of countless experiments to ascertain its essential character- 
istics. The resultant array of facts, with, it must be confessed, 
not a few theories, has given rise to repeated discussions upon the 
disease, which naturally have led to a better understanding and 
the acceptance of a practically uniform view of its nature. The 
chief points of these controversies have been in regard to the 
etiological factors involved. Our study of these must include a 
consideration of both the predisposing and the exciting causes. 

Predisposing Causes. — Chief among the predisposing causes is 
the presence of a general nervous habit of the patient, which may 
be very evident to the eye of the physician, or may be elicited 
only after a careful examination. This may manifest itself with 
a multitude of intervening gradations, as the peculiar condition is 
produced apparently by an excess of nervous force, or, on the 



REFLEX NASAL NEUROSES. 195 

other hand, as the directly opposite condition from a lowered tone 
of the nervous system. It may be the manifestation of an inherited 
tendency, as seen in families of a neurotic diathesis, or it may be 
acquired, as seen sometimes following some prolonged or severe 
nervous strain. We wish also to emphasize this important fact — 
namely, that a goodly proportion of the various predisposing ele- 
ments recognized by the profession are such simply as they tend to 
produce or increase this underlying nervous element. Thus we 
shall cite the fact that hay fever is a disease more of the highly 
educated than of the illiterate, more frequently occurring in those 
whose calling involves mental and nervous strain than in those 
following mere mechanical labor ; and we firmly believe that the 
influence these agents exert is not intrinsically predisposing to 
the disease, but acts secondarily by an effect upon the general 
nervous structures. The psychical element, claimed by some as an 
influential factor, is in reality but a manifestation of this neurotic 
temperament, and is curiously illustrated by the case of Mackenzie's, 
in which the attack was induced by the sight of an artificial rose. 
Another important factor not to be overlooked is the chemical 
alteration of secretions (see page 53). 

The numerous theories as to the etiological factor in this trou- 
blesome disease proves conclusively that as yet there has not been 
established a definite cause. It may be that different conditions 
act as etiological factors ; in fact, it is my belief that not all 
cases which we call hay fever, or hyperesthetic rhinitis, are due to 
any one cause ; or if to any one factor, that factor is found in the 
altered chemistry of the secretion of the individual. Sensitive 
areas within the nasal cavity or irregularities of formation of the 
cavities are factors in some cases ; yet such areas or irregularities, 
instead of being etiological factors, are merely more susceptible to 
the irritant from within. The sensitive areas of the nasal mucous 
membrane as observed in certain individuals no doubt render that 
individual more susceptible to irritants, but cannot be the sole 
cause of the hay fever, as many individuals having no such sensi- 
tive area suffer from aggravated cases of this malady, and others 
having equally sensitive areas do not suffer from hay fever. Any 
individual having nasal obstruction in the form of deflected sep- 
tum, narrow nostrils, polypoid growths, etc., or the neurotic type 
with lowered vitality, may suffer a more aggravated form of this 
disease than those not having such nasal obstruction or underlying 
systemic condition. I am persuaded, after making a series of 
examinations of the saliva in certain individuals afflicted with hay 
fever and those not afflicted with the disease, that in many cases the 
causes of local irritation in the nasal mucous membrane is brought 
about by some chemical change in the constituents of the mucus- 
secreting glands (see page 57). It is a well-known fact that in 
many cases of hay fever the irritation is not limited to the nasal 



196 NASAL NEUEOSES. 

mucous membrane. The eve and the mucous membrane of the 
stomach and bladder, and even intestines, may be markedly irri- 
tated. In the ammoniacal cases (the so-called horse fever cases) 
there is always a certain amount of irritation of the conjunctiva, 
occasionally to the extent of a severe conjunctivitis. In an alka- 
line saliva with sulphocyanids present we frequently see the 
abrasion about the mucous membrane of the pharynx, tongue, and 
cheek ; in fact, a herpetic condition may occur. This is especially 
true in the excessive alkaline cases due to the potassium or the 
ammonium sulphocyanid. Such cases could scarcely be explained 
on the basis of a reflex neurosis. In such cases the mucous 
membrane suddenly becomes engorged, and is exceedingly sen- 
sitive, with profuse watery, irritating discharge. This comes on 
suddenly, often without any apparent external irritant, which 
looks very much as though at times there accumulated in the 
system a material which, when it had reached a certain point 
of accumulation, there was an effort on the part of the mu- 
cous membrane to throw off. In other words, that the human 
body is nothing more than a chemical laboratory performing its 
daily function and manufacturing and liberating certain normal 
chemical ingredients and constituents, and that under certain con- 
ditions the chemistry of these secretions is altered, and the manu- 
factured product, instead of performing a physiological function, 
serves as a pathological process. This may be in the form of a 
secretion or in the form of an infiltration or deposit. We have 
such a condition exemplified in uric-acid diathesis, but I believe, 
in many cases in which we attribute the symptoms- present to uric 
acid, that instead of uric acid we have some other organic com- 
pound formed, due to perverted chemistry and deposited on or 
within the tissue. I have been able to demonstrate this in a num- 
ber of cases in diseases of the nose and throat. I think that there 
is quite a field for investigation in this line to determine if there is 
not in many cases manufactured within the system the irritating 
material which brings about the attack. This can best be deter- 
mined by a study of the saliva, as is shown on page 53. The 
question may be asked, " Why does this come on at certain times 
of the year?" It is a well-known fact that climatic and atmo- 
spheric conditions produce changes in function and secretion, that 
certain diseases are prevalent at certain times of the year, and that 
under certain climatic and atmospheric changes individuals are 
more susceptible to disease. This must be due to some altered 
condition of the individual which renders him susceptible to dis- 
ease, owing to altered chemistry and lowered cell-resistance. 
Temperature and climatic changes do affect the chemistry of the 
secretion. As to the effect of pollen in certain cases, is it not 
possible that, owing to some peculiar constituent of the secretion 
of the mucous gland, there is deposited in or on the nasal mucous 



REFLEX NASAL NEUROSES. 197 

membrane certain material which, when brought in contact with 
certain extraneous material, as pollen, through some chemical 
action, produces a material which brings about the irritation and 
causes an attack of what is known as hay fever ; or that the ex- 
traneous material merely acts as a stimulant to the mucous glands, 
and causes a flow of mucus, which, owing to its altered chemistry, 
acts as an irritant ? This is exemplified in the cases in which the 
ammonia salts bring on an attack identical with that produced by 
the rag- weed pollen. The cases referred to on page 55 are ex- 
amples illustrating this point. There is no question that in such 
cases the irritation is caused by some product of chemical action. 
This altered secretion, as an etiological factor, may be divided into 
three classes : 

1. The class in which the secretions when, coming to the sur- 
face, are non-irritating, but undergo chemical change and produce 
irritation. This may be either acid, alkaline, or neutral. 

2. Cases in which the secretion, when it comes to the surface, is' 
irritating without any chemical change. 

3. When the secretion comes to the surface it comes in contact 
with certain extraneous materials, and certain secretions coming in 
contact with certain materials, produce by chemical change an irri- 
tant ; hence the term ragweed fever, rose cold, etc. 

The sulphocyanids, as well as the reaction, alkaline or acid, of 
the secretion play an important part. All the cyanid preparations 
are poisonous and the sulphocyanicl is especially so. In individuals 
of the nervous type the low vitality, the low-cell resistance, and 
general debility,, which in themselves are predisposing factors — 
may not such cases be simply autoinfectious ? Cases in which the 
sulphocyanids are present are necessarily autoinfected cases. In- 
dividuals having such autoinfectious are usually of the neurotic 
type. The question involves organic chemistry, and anyone 
familiar with the work recognizes the time and labor necessary to 
Avork out such chemical formula?. However, I have done sufficient 
laboratory work in the past twelve years to convince me that on 
this basis we can relieve many cases of hay fever. That the 
chemistry of the secretions has to do with the causal factor I have 
illustrated in a number of cases by rapidly changing the reaction 
of the secretion either from acid to alkaline or from alkaline to 
acid, and in many instances I have been able either to partially or 
wholly avert the attack. Owing to the fact that the mucous 
membrane of the nasal and nasopharyngeal cavities is supported 
by bony structures, and that the blood-supply comes largely 
through the bony structure, there is a greater tendency to conges- 
tion and deposit and infiltration of this structure, which may ex- 
plain why so often the irritation is limited to the nasal coats. 
The susceptibility of these parts is illustrated in the administra- 
tion of certain drugs. The nose is the susceptible point. May 



198 NASAL NEUROSES. 

not the so-called susceptibility of the mucous membrane be ex- 
plained by chemical changes? The effect of these altered secre- 
tions is also seen in cases in which the mucous membrane is 
dry, with a sensation of burning and irritation, and yet there is 
practically no inflammatory process. This certainly is due to an 
altered secretion coming in contact with the mucous membrane 
surface and producing local irritation and not a structural change. 

In many cases in which there is altered chemistry of the saliva 
the patient complains of an excessive flow of this secretion and in 
some instances of a soapy taste in the mouth. The three condi- 
tions, excess of alkalinity, excess of acidity, and the neutral 
condition each play an important part and each produces a dif- 
ferent line of symptoms. 

The remaining predisposing causes may be explained by the 
action which they exert favorable to the development or local effect 
of the active causative principles. The disease occurs more often in 
men than in women, and usually before the fortieth year. Cases 
do occur, however, in early and in late life, one being recorded in 
an infant of two years, whose parents also suffered from the com- 
plaint, and several in patients over seventy. The geographical 
distribution shows the disease to be more prevalent in America 
and in England ; and in the former country all of the States seem 
to be visited by it, though with perhaps less frequency in the 
western and southern sections. High altitudes exhibit a practical 
absence of the disease, and offer generally a complete relief to the 
sufferer during the period of the attack. The immunity does not, 
however, extend to every case, and a mountain resort giving a 
freedom from the attack to one patient may have no effect upon, 
or even aggravate, a second case apparently identical with the 
first. Race predisposes, the English and Americans furnishing 
the great majority of cases ; and, curiously enough, cases occurring 
in Asia and Africa are usually confined to these two races, while 
the natives seem not to be affected. The Indian and Negro are 
apparently immune, and so far as the records go, the Chinese seem 
but little susceptible, though tea-drinking and the use of narcotics 
are claimed by certain authorities to be predisposing factors in 
other races. The influence of the neurotic temperament has 
already been mentioned, and this must also be regarded as the 
expression of the influence that is usually accredited to inheritance, 
idiosyncrasy, and in like manner to the patient's personal hygiene. 
The disease seems also to be of an aristocratic nature, in that it is 
more prone to occur in those of social standing and education than 
in those of humbler spheres, and the day-laborer or farm-hand 
with his simple, healthy life is far less susceptible to the malady 
than is his town or city relative with his more or less artificial 
" high-tension " mode of living. Certain conditions which formerly 
were held by some to be active causes must, in the light of better 



REFLEX NASAL NEUROSES. 199 

knowledge, be considered as merely predisposing. Such are heat, 
sunlight, overexertion, mental or muscular, and exposure to a 
dust-laden atmosphere. A condition simulating hay fever is fre- 
quently observed on shipboard or at the seashore ; in fact anywhere, 
if the individual is subjected to the sun's glare from the surface 
of the water. This is due to the actinic ray. This white 
actinic ray, to certain individuals, seems to produce a violent con- 
gestion of the nasal mucous membrane and also of the conjunc- 
tiva and skin. In such susceptible individuals there will be 
produced a series of symptoms almost similar to hay fever. The 
patient's nasal mucous membrane suddenly congests, breathing is 
obstructed, the eyes itch and burn and are suffused with secretion ; 
there is slight frontal headache, itching of the roof of the mouth, 
and burning sensation within the vault of the pharynx. Almost 
instant relief can be obtained by the patient going into a dark 
room or by covering the face with a red or green veil. Atten- 
tion has been called to the irritating effect of the actinic rays by 
Finsen. This irritating effect of the actinic rays is not alone lim- 
ited to the mucous membrane, but in certain individuals, with 
certain underlying systemic cause, no doubt, the actinic rays will 
produce marked irritation of the skin, causing erythema. The 
wearing of a red or green veil will, in many cases, prevent it. The 
chemical action of the sun's rays is an old and established fact, 
but just what chemical change is produced that would cause such 
irritation of the nasal and conjunctival mucous membrane no one, 
so far, has been able to work out. Pathological conditions or mal- 
formations of the nasal structures predispose in no small degree. 
These include prolonged acute catarrhal inflammations and the 
chronic and hyperplastic forms of rhinitis, chronic cyanotic condi- 
tions, deviations or spurs of the septum, enlarged turbinates, extreme 
turgescence of the mucous membrane, various tumors, especially 
polyps, and obstructive agents, temporary or permanent, of what- 
ever character. The local catarrhal conditions accompanying or 
following the infectious fevers, especially if the patient is greatly 
weakened by the disease, predispose, and active morbid processes 
in adjacent regions have a proportionate effect. The gouty or 
rheumatic diathesis is regarded by some as predisposing, and, 
finally, in this condition the influence of season must be considered. 
In America the majority of cases occur in the late summer or 
autumn months. Cases do occur earlier in the year, and the 
attacks seem to be governed by the climatic conditions favorable 
to the peculiar irritant in each case. It must not be forgotten, 
however, that an attack may be provoked at any time of the year 
by certain irritation ; not infrequently the attacks may occur in 
more than one yearly period. 

Exciting Causes. — There is little doubt that the experiments 
of more recent years have given a correct solution of the exciting 



200 NASAL NEUROSES. 

cause, in most cases, in the pollen theory. Various causes have 
at times been advocated, such as heat, sunlight, ozone, ammonia, 
benzoic acid, dust, and overexertion, either acting singly or in 
combination. Blackley, however, has proven that the pollen of 
plants does, in the majority of cases at least, constitute the excit- 
ing cause. His experiments showed — first, that the inhalation of 
pollen caused an attack ; second, that the intensity of the symp- 
toms varied proportionately to the amount of pollen suspended in 
the air, becoming less marked, for example, after a heavy rainfall 
had washed the air of its impurity ; and third, that the other 
causes given, acting alone, were not sufficient to produce the disease. 
In spite of this, however, cases do certainly occur presenting all 
the phenomena of a typical hay-fever attack, and yet so far out 
of " pollen season," if we may express it, and so obviously due to 
another irritant, as to dispel belief in pollen causation in the par- 
ticular instance. As examples, may be cited reported cases in 
which the attacks invariably followed inhalation of ammoniacal 
fumes, salicylic compounds, ipecac, etc. ; and a case of typical hay 
fever in the author's practice. In this case the patient was com- 
pletely incapacitated by the severe paroxysms, which were due to ex- 
posure to dusty air, and occurred at any season of the year. Sus- 
ceptibility of certain individuals to special irritants is illustrated in 
a family, including father and children, in which, if any mem- 
ber went near the horses (horse fever), even when out driv- 
ing, the ammoniacal fumes would bring on an acute attack 
of coryza, simulating, in every respect, hay fever. The at- 
tack would clear up in a few hours, only to recur if simi- 
lar conditions existed. Pollen and plant emanations are, 
however, undoubtedly the cause iu the majority of cases. No 
particular variety of plant can be held responsible for every case 
of the disease — a fact aptly illustrated by the botanical synonyms 
the malady bears. This fact also explains the protection which 
certain resorts offer to some sufferers and not to others, because 
of the characteristic flora of the adjacent territory. Occasionally, 
some resort of this character suddenly loses its protective nature, 
either from the introduction of the obnoxious plant into the imme- 
diate region, or by a shower, as it were, of the minute pollen 
particles carried by an air-current from a remote distance. Gar- 
ments carefully packed by the patient before leaving for his cus- 
tomary resort and opened there may carry sufficient of the irri- 
tant to cause a paroxysm. The influence of dust is also explain- 
able by its contamination with pollen, although in itself it may 
seriously aggravate and, we believe, even provoke the attack. 
Botanists and florists afflicted with the disease have to leave their 
occupations during the efflorescence of certain plants, their sus- 
ceptibility ceasing as the flowering season of the plant comes to 
an end. The varieties of plants producing irritation are many. 



REFLEX NASAL NEUROSES. 201 

The list includes the roses, the grasses, cereals such as oats, barley, 
and rye, and certain of the shrubs, and trees like the peach and 
the plum. In America the rag-weed is held to be the chief cause, 
and seems to be responsible for the greater proportion of cases, 
while the grasses play a very minor part. Many cases seem sus- 
ceptible in varying degree to the irritation of different plants, and 
especially to one ; indeed, it is not unlikely that a combination of 
pollens may be essential for the production of an attack from this 
cause. How the irritant produces its effect is a matter largely of 
conjecture ; it may be by mechanical impact, continued presence, 
or by the impregnation of the nasal secretion with some intrinsic 
substance irritant to the hypersensitive membrane. It is not 
difficult to conceive how the alteration in the pollen under the 
warmth and moisture of the nasal space could easily lead, in the 
present day of germ-discovery, to its being regarded as a peculiar 
germ, and reported as such. This idea is, of course, long since 
exploded. 

Another element, however, besides the general neurotic ten- 
dency and the exciting cause, is evidently an essential factor in the 
etiology, since not all people of a nervous temperament, who inhale 
perhaps as much or more of the irritant principle even than those 
suffering from the disease, acquire hay fever. This element is 
supplied by the existence of areas of increased intranasal irrita- 
bility to the irritant substance. Just what is the nature of this 
local neurosis is difficult to explain, the generally accepted view 
being that it is a functional derangement of the vasomotor appa- 
ratus influenced by a peripheral hypersensitiveness to certain 
external agents. Certain it is that there exist in the nasal mucosa 
of sufferers from hay fever areas of hypersensitiveness, irritation 
of which is at once followed by an exacerbation of the charac- 
teristic symptoms ; and that these areas are the receptive points 
of this peculiar irritation is further proven by the fact that their 
disorganization by cautery or acids limits the disease. To sum up 
briefly, then, hay fever is dependent upon — first, a neurotic habit 
producing a susceptibility to the disease ; second, a local nervous 
condition which may or may not be associated with nasal irregu- 
larities ; and which is directly influenced by, third, the external 
irritant, which in the majority of cases is pollen or other product 
of an obnoxious plant. 

Pathology. — The disease presents no characteristic structural 
pathological lesion. During the attack all the evidences of a ca- 
tarrhal inflammation are present. There is, however, a peculiar 
pallor of the mucous membrane observed in long-standing cases. 
Between the attacks the various morbid processes or malformations 
which have been mentioned as predisposing to the disease present 
their peculiar characteristics, apparently unmodified by the occur- 
rence of the periodical exacerbations. A very characteristic feat- 



202 



NASAL NEUROSES. 



lire of the disease is the existence in the nasal membrane of areas 
of hyperesthesia, occupying various sites and varying in number. 
One is located at the posterior extremity of the inferior turbi- 
nated body and the corresponding part of the septum ; another at 
the anterior extremity of the same turbinate. A third is found 
at the anterior part of the septum or nasal wall, just within the 
angle bounding the vestibule ; and a fourth sometimes is found on 
the mid-surface of the middle turbinate (Fig. 64). That these 




Fig. 64.— Nerve-supply of nasal mucosa, showing position of sensitive areas. 

areas are essential to the production of the attack is seen in the 
exacerbations following their mechanical irritation — a feature 
which we regard also as indicating that other irritants than 
those of plant origin are in some cases causative — a fact already 
stated in considering the etiology. Just why this abnormal irri- 
tability should exist in these sites is possibly explained by the 
anatomy of the membrane. It has been proven by histologists 
that the terminal filaments of the nerve-supply to a mucous mem- 
brane penetrate its basement membrane to a certain extent some- 
what in the same manner that a hand fits its fingers into the 
fingers of an encasing glove. It is possible that at these sites 
there is a deeper penetration than normal, or even a projection 
permitting the peculiar irritant to approach the susceptible fila- 
ments more closely. The same condition would result from a 
thinning of the membrane, either from a temporary or permanent 



REFLEX XASAL XEUROSES. 203 

desquamation of the epithelium in pathological processes interfering 
with the nutriment of these structures, as, for example, the press- 
ure of polyps or other growths. It is not improbable also that 
the areas may possess an increased amount of these nervous ele- 
ments, more "than might be considered a normal number. The 
influence of a neighboring inflammatory process, by its action upon 
the terminal nerve-filaments, keeping them, as it were, in a subacute 
inflammatory condition, is no doubt a potent factor in increasing 
an especial susceptibility. Rarefaction of the air in the nasal 
spaces posterior to an obstruction, and taking place at each 
inspiration, is given by a prominent authority (Bosworth) as a 
determining factor in their production. A fact, possibly of signifi- 
cance, is limitation of the sensitive areas to the respiratory region, 
together with their practical absence from the upper or olfactory 
region. The presence of the neurotic taint, as influencing the 
susceptibility of the areas to the special irritation, must always 
be considered. 

Symptoms. — The attacks occur usually at intervals of a year, 
reappearing at a definite period. In many instances, the patient 
is aole to tell the exact day the attack may be expected, and fre- 
quently with such accuracy as to cause suspicion of a powerful 
mental influence in its causation. Attacks may, however, occur 
both in summer and fall, or be induced at other periods by the 
peculiar irritation ; and, in a few extreme cases, the exhibition of 
a picture or artificial production of an obnoxious plant has led to 
the onset of a paroxysm through association of ideas. The symp- 
toms of an attack are those of a severe rhinitis, which, however, 
is accompanied at times by bronchial manifestations, so that it is 
necessary to consider both the catarrhal and the asthmatic symp- 
toms to describe the disease properly. The onset is usually rapid, 
with sudden itching in the nose, followed by violent and prolonged 
sneezing and an abundant thin, watery discharge from the nostrils, 
which may excoriate the lip and alse nasi. The membrane becomes 
swollen and turgid, and blocks up the nasal spaces. There is 
extreme tenderness of the membrane, and fissures or excoriations 
may develop. There is much lacrimation, with stinging and 
pricking of the conjunctival surfaces, especially at the inner 
canthi. Photophobia is extremely apt to be present, and chemosis 
is not uncommon. The eyelids become puffy, and neuralgic pains 
in the eyeball or back of the head are frequent. As the attack 
advances, the discharge becomes seropurulent and shows a ten- 
dency to gravitate on lying down. Pseudomembrane may form, 
and in one patient of my own this membrane had undergone par- 
tial organization, causing bleeding when removed. There is a dull 
pain over the nasal bridge, and an accompanying frontal head- 
ache. Tinnitus aurium, temporary loss of smell and taste, par- 
tial deafness from involvement of the Eustachian orifices in the 



204 NASAL NEUROSES. 

swelling of the membrane, extension of the inflammatory process 
to the connected sinuses, and an associated pharyngitis with its 
characteristic symptoms are not unusual in its course. Itching of 
the roof of the mouth is frequently present. The attacks vary in 
intensity, proportionate, possibly, to the amount of the irritant in 
the atmosphere, and vary in duration from several days to a few 
weeks. If the attack be severe and prolonged, the patient becomes 
irritable, and his general health suffers. Malaise, incapacity for 
mental work, chilliness, pyrexia of moderate degree, and the 
whole chain of digestive disorders appear. The face may become 
generally swollen and itch, or in some cases the whole body may 
itch, or urticaria may appear. The scalp may become hyper- 
esthetic. On inspection there is nothing in the appearance of the 
nasal mucosa to differentiate it from a severe simple catarrhal 
inflammation, save that, as already mentioned, the membrane in 
cases of long standing is apt to have a peculiar pallor. If, how- 
ever, a probe be used in exploration, the sensitive areas may be 
located on the membrane by the sudden intensification of the 
symptoms which the irritation produces. One or more of these 
may be found, and they may not be limited to one nasal space 
alone, but in common with the other manifestations occur in both. 
The attack shows, if untreated, no tendency to abate so long as 
the irritating medium is present in the atmosphere, but continues 
with varying intensity until this is removed or its power of irrita- 
tion annulled by proper remedial measures. Usually its cessation 
is as sudden as its onset, and little or no trace of its occurrence 
remains. In some cases the paroxysms are preceded by pre- 
monitory symptoms much like those of the attack itself, but of 
less severity and intensity, apparently resembling a delayed onset. 
These may occur several days or even weeks before the actual 
onset, and comprise slight attacks of sneezing, pain in the eyeballs, 
etc. Some cases run a course not so sudden in origin, and decline, 
but gradually increasing in intensity until the maximum is reached, 
and as gradually declining to the normal condition again. Asth- 
matic symptoms occur in many instances, though whether they 
originate from the same cause or exist as an independent affection 
is a question undecided as yet. The symptoms do not differ from 
those of bronchial asthma as a separate affection, and usually they 
do not begin until the attacks have become well established. They 
vary in severity also ; occasionally the patient has a blood-streaked 
expectoration following the paroxysms, and, rarely, emphysema 
has occurred. The attacks may take place simultaneously with 
the catarrhal symptoms or they may follow their subsidence ; 
they may last for a few hours only or may be of more extended 
duration. Usually they occur during the day. If coincident with 
the catarrhal paroxysm, the onset is usually insidious, the asth- 
matic symptoms increasing in severity as the former condition 



REFLEX NASAL NEUROSES. 205 

progresses. In such a case it may cease with the attack or con- 
tinue as a separate affection. Not infrequently the patient may 
have asthmatic attacks occurring at other periods and may develop 
into a confirmed asthmatic, dragging out the miserable existence 
which that affection entails upon its victims. Finally we may 
mention the curious fact that in some cases of long duration the 
catarrhal paroxysms may be replaced by an attack of asthma. 

Diagnosis. — The diagnosis is comparatively simple. The 
severe and stubborn catarrhal symptoms, with perhaps the super- 
added asthmatic manifestations, the areas of hyperesthesia in the 
nasal membrane, the general neurotic state of the patient, the peri- 
odical recurrence of the paroxysms, and the possible identification 
of the exciting cause furnish all the necessary diagnostic points. 

Prognosis. — The outlook, so far as effect upon life is concerned, 
is good. The disease has a tendency to disappear permanently as 
old age approaches. The termination of each attack may be con- 
fidently looked for sooner or later, and with equal certainty may its 
periodical return be predicted, unless treatment has been of avail. 
The outlook as to a permanent cure is fairly favorable, especially 
if the condition is early taken in hand. The more annoying 
symptoms of the attack may be relieved in the greater propor- 
tion of cases. 

Treatment. — The treatment of this troublesome and frequently 
occurring disease, owing to the varied etiological factors and to 
the fact that each individual presents symptoms peculiar to his 
own case, should be varied to suit individual cases. While the 
condition is generally conceded to be a neuropathic nasal reflex, 
yet there are a number of predisposing factors ; that the pollen of 
plants is an exciting factor no one will dispute. The predispos- 
ing factors may be roughly divided into three groups : 1. The 
constitutional diathesis. 2. A general neurotic condition. 3. 
Local nasal irregularities, with hypersensitive areas. These may 
exist separately or combined. Before speaking of the treatment 
of the separate conditions, a few words as to the general treat- 
ment. 

All varieties, without respect to predisposing factor, are relieved 
or the attack avoided by the individual residing, before and dur- 
ing the time of the expected attack, in some locality exempt from 
the affection, or in localities exempt from the pollen of plants. 
Either he should visit mountainous regions, such as the AVhite 
Mountains, or take a sea-voyage. As this plan of treatment is 
not always practicable, something must be done for the relief of 
the condition before and during the attack. If the individual be 
seen before the occurrence of the paroxysm, a careful examination 
should be made to determine, if possible, the predisposing factor, 
and treatment should be instituted, regardless of cause, for from 
six weeks to two months before the regular occurrence of the 



206 NASAL NEUROSES. 

attack. The treatment of hay fever may be subdivided into 
local and systemic. It is a well-known fact that there are 
many cases of hay fever that local treatment, instead of reliev- 
ing, seems to either aggravate the symptoms or bring on an at- 
tack. Occasionally, however, the alkaline or acid douches seem 
to afford some relief. This is easily explained by the fact that 
the alkali or acid would change the reaction of the irritating 
secretion ; yet if either solution were used in the wrong type of 
case, this influence would only be aggravated. Clinical expe- 
rience has proven this to be true. 

Do not understand me to say that this is applicable in all cases. 
Some cases certainly receive considerable benefit from local seda- 
tives, and if certain sensitive areas are removed, the local suscep- 
tibility on the part of the individual would be lessened. At the 
same time the underlying cause would still remain. 

The plan of treatment which I have followed, and which 
has been based on the chemical analysis, necessarily varies in dif- 
ferent individuals. The general plan, however, is, first, attention 
to the secretions. I mean by that the process of elimination — 
active intestinal purging, stimulants to the liver, and free action 
of the skin. 

Second, depending on whether the condition is alkaline, acid, or 
neutral ; whether it is due to the presence of ammonium salts, the 
sodium salt, potassium salts, or whether there are present sulpho- 
cyanids, lactic acid, or oxalic acid. To meet these conditions 
citrate of soda, citrate of potash, lactate of soda, benzoate of soda, 
which renders inert active compounds, boric acid, dilute hydro- 
chloric acid, dilute nitric acid, various forms of salicylates, aspirin, 
sodium chloride — all may be used to counteract a certain chemical 
ingredient present in the saliva, so that the drug must be selected 
purely on this basis. The patient should always be instructed to 
drink plenty of water. 

Constitutional Diathesis. — As to the cure or treatment of this 
condition, I think the sooner we work on the same basis as if 
we were treating a cold or an attack of acute rheumatism, the 
sooner will we reach a definite and decided plan of treatment ; in 
other words, that an attack of hay fever should be treated the 
same as an attack of cold. The nose is the susceptible point; 
yet if the patient did not have a nose, it would not prevent his 
taking cold ; the same is true of hay fever. The cold can be cured, 
but there can be no guarantee offered the patient that he will not 
have another cold. If altering the chemistry of the secretions in 
an individual suffering from hay fever will relieve the attack, then 
just as soon as similar conditions arise again the patient will be 
liable to another attack. In many cases which I have treated I 
have been able to relieve the patient and allow him to pass com- 
fortably through his hay-fever season by simply attending to the 



REFLEX NASAL NEUROSES. 207 

reaction of his secretions, changing the reaction of the secretion at 
each sign of a repetition of the attack, administering such drugs, 
acids, or alkalines as are necessary to obtain such reactions, and 
carefully keeping the secretion of the individual most active. On 
this basis I have been able to relieve a much larger percentage of 
cases than heretofore by any local treatment or any theory of 
neuroses or uric-acid diathesis. 

Many solutions have been recommended and are used for local 
application to the nasal mucosa. My own experience and from 
what I have observed in others, and the almost universal expe- 
rience of the patient, is that local applications only give slight 
temporary relief. This supports the theory that the irritant comes 
from within — at least, that the original irritant comes from within. 
Adrenalin solutions, cocain solution — in fact, all the sedative solu- 
tions — in many cases give only temporary relief. In my expe- 
rience this is true in the majority of cases. 

Neurotic Temperament. — The neurotic variety forms the greater 
number of cases, and is by far the most difficult condition to 
relieve. The sending of the individual to localities exempt from 
the disease is the only possible method of relief, although much 
can be done by careful attention to the individual's habits, such as 
insisting upon outdoor exercise and careful diet, together with 
constitutional treatment. Before the attack the patient should be 
treated for not less than eight weeks, or, as the condition exists 
during the entire year, the treatment may be instituted much 
earlier and occasionally interrupted. The best remedial agents for 
this condition I believe to be iron or arsenic. Of the preparations 
of iron, the best results will be obtained by the administration of 
the original Blaud's pill, one pill to be taken three times a day one 
hour after meals. Two or three weeks before the attack may be 
substituted a pill containing -^ grain of the double sulphid of 
arsenic. During the attack the same treatment should be con- 
tinued, and the means as given under the variety above for the 
relief of the nasal congestion be resorted to. The administration 
and dose of drugs are of necessity controlled by the general condi- 
tion presented by the individual. 

Irregularities of the Nasal Cavities and Hyper sensitiveness. — 
Necessarily, the treatment in such cases would consist in the cor- 
rection of the existing irregularity, whether in the form of deflec- 
tions of the septum, nasal polypi, inflammatory or non-inflamma- 
tory thickening of the mucous membrane, or any condition which 
tends to produce a chronic congestion. Treatment for such con- 
ditions should be instituted any time between attacks. In the cases 
where there are markedly sensitive areas, they may be destroyed 
by means of the cautery, actual or potential, before or during the 
attack. The local treatment given in the other conditions for the 
immediate relief of the paroxysm is equally applicable in this form. 



208 NASAL NEUROSES. 

The turgescence of the mucous membrane, with its consequent ex- 
cessive secretion, may be relieved by linear cauterization or scari- 
fication, care being taken not to destroy to any extent the nasal 
mucous membrane, and thereby avoid any after-effects through the 
formation of scar-tissue. For the relief of the continued irrita- 
tion of the nasal secretion in cases in which the treatment given 
above fails, the administration of a pill containing 2 grains of 
bromid of quinin, -^yo" grain of atropin, and -J- grain of codein, 
three times a day is highly beneficial, but should not be long 
continued . The inhalation of the fumes of burning stramonium 
leaves — in fact, any of the common inhalations, afford only tem- 
porary relief. When the predisposing factors exist in combination, 
the treatment must be combined to suit individual cases, and, 
necessarily, no definite plan can be formulated. In all cases, gen- 
eral hygienic measures, such as the regulation of food, clothing, 
and habits of life, should be rigidly enforced. In all cases, the 
treatment should be directed to the localization and controlling of 
the predisposing factors, remembering that the nasal symptoms 
and the existing hyperesthetic condition are only local manifesta- 
tions. Occasionally in severe cases there is thrown out on the 
nasal mucous membrane a highly fibrinous exudate. In such 
cases the exudate should be thoroughly removed, and the tissue 
coated over with a 20 per cent, chromic-acid or 3 per cent, chlorid- 
of-zinc solution. After the acute attack, should there be any 
existing catarrhal condition, the treatment given under Acute 
Coryza (page 78) should be employed. 

Cough. — Nasal cough can be caused by simple coryza, simple 
chronic and hyperplastic rhinitis, spurs and deflections of the septum, 
polyps, engorgement of the cavernous tissue over the vomer, adenoid 
growths in the vault of the pharynx, enlargement of the middle 
turbinate, or simple vasomotor changes in the nose. The mechan- 
ism of its causation is supposedly due to the irritation of the 
so-called cough-area of Mackenzie by any of the means men- 
tioned above. A cough that has proved intractable to ordinary 
means of treatment should suggest intranasal inspection as a rou- 
tine procedure in the management of the case. Should patholog- 
ical alteration, malformation, or irritability of the intranasal spaces 
be found, they should be eliminated as possible factors in causa- 
tion of the cough by appropriate treatment. Cocain applied within 
the nose may lessen the severity of the cough, in which case the 
nasal origin of the reflex is assured. A failure of the cocain, 
however, to cause anesthesia in the excitable region does not elim- 
inate the nose from the role of exciting cause, but further search 
for abnormality or disease should be instituted and remedied, if 
found before abandoning the field. 

Pharynx and Mouth. — Due to intranasal disease, there have 
been reported as occurring reflexly in the pharynx and mouth, 



EEFLEX NASAL NEUROSES. 209 

hyperesthesia, paresthesia or imaginary foreign body, neuralgia, 
paresis of the palate, dysphagia (paretic and cesophagismus), hic< 
cough, and salivation. 

I<arynx. — Of the neuroses affecting the larynx, aphonia is to 
be mentioned. Cases of aphonia, independent of actual laryngeal 
disease, have been reported cured . by medication of the nose. 
Whether the cure be due to the revulsive action of the methods 
employed or to the actual elimination of a nasal etiologic factor 
might be questioned from either standpoint. 

That pathological conditions of the nose or nasopharynx may 
produce glottic spasm or spasmodic croup, clinical data clearly 
substantiate. Adenoids of the nasopharynx have been found in a 
large number of cases of laryngeal spasm or spasmodic croup, and 
Lennox Browne seems to think that their removal will effect a 
cure. J. A. White reports a case of croup in which the irritation 
of operative interference, due to removal of adenoids, was suffi- 
cient to cause a severe laryngeal spasm a day later, controlled, 
however, by the application of cocain, showing that neither ade- 
noids nor other obstructive lesion was the cause of the spasm, 
which, from the prompt result obtained by the cocain, seems to 
have been clearly due to reflex irritation from the nasopharynx. 

Asthma. — Granting that asthma be due to vasomotor paresis 
and bronchial spasm, and admitting the alteration of the nerve- 
centers with predisposition to nervous disturbance in the bronchial 
region, it is fair to assume that nasal as well as other forms of 
peripheral irritation may reflexly produce the asthmatic paroxysm. 
The irritation within the nose may be brought about by inflamma- 
tory pressure on the terminal-nerve filaments in the mucosa, or 
may be due to turgescence of the erectile tissues caused by trans- 
mitted vasomotor alterations from distant parts of the economy — 
e. g., the eye, stomach, liver, intestines, etc., or from a diseased 
ganglion itself, or from any pathological lesion in the intranasal 
spaces. In a search for the underlying cause of the bronchial 
spasm, eliminate cardiac trouble, renal disease, malarial influence, 
gastric and intestinal disturbances, irritation of the cervical sym- 
pathetic by enlarged glands and growths, chronic bronchitis, skin- 
lesions, sexual irritation, rheumatism, gout, and psychical causes, 
then examine the nose. There is nothing peculiarly pathognomonic 
in the symptoms or physical signs of nasal asthma, the paroxysms 
being identical with those due to other lesions, except that imme- 
diately preceding and after the attack, the rales heard on aus- 
cultation are dry ; while in the form due to bronchitis they are 
moist. 

Asthma, as a disease or a symptom of a disease, is character- 
ized by dyspnea, both inspiratory and expiratory. That there are 
many varieties of asthma and many etiological factors is proven 
by the variableness of the attacks, not only as to symptoms, but 
H 



210 NASAL NEUROSES. 

as to time. In some cases the attack is brought on by excitement 
or mental conditions, while in others it is brought about by exter- 
nal irritants. Some attacks occur in the morning ; others at 
any hour during the day, while others are more frequent in the 
evening. 

Season predisposes some individuals to attacks. Warm, dry 
summer months the patient is usually free from attack, except in 
some conditions, as hay asthma. Dampness during any season of 
the year predisposes to an attack. 

This peculiar disease may be associated with systemic condi- 
tions, may follow bronchial or pulmonary lesions, may also be as- 
sociated with hepatic, renal, cardiac, and intestinal diseases. On 
the other hand, individuals in perfect health may be seized with 
an asthmatic attack, and in many cases I believe it to be asso- 
ciated with some chemical change in the secretion, in which the 
irritant is brought to the surface of the mucous membrane through 
the product of the gland secretion. 

The spasmodic condition is, no doubt, a vasomotor paresis, but 
the cause unquestionably differs in individual cases. 

In hay fever associated with asthmatic attacks I firmly believe 
that the underlying irritant cause of the so-called hay fever in the 
fulminating cases is the etiological factor of the asthma. 

Numerous exciting factors may be given : 

Nasal obstruction. Polypoid or any form of new growth. 
Abnormalities, either acquired or congenital, interfering with 
breathing. 

Injuries to the nose have been followed by asthmatic attacks. 

An enlarged thymus gland by pressure on the trachea will pro- 
duce expiratory dyspnea, the so-called thymic asthma or thymic 
tracheostenosis. 

Vasomotor variety may be excited by intrinsic causes : The 
autoinfections ; emotions. Also by extrinsic agents : climatic con- 
ditions, etc. Any form of congestion of the nasal mucous mem- 
brane may be an associated factor. 

Under the toxic causes, the autointoxications, such as through 
the intestinal tract or from the salivary secretion ; in gout, rheu- 
matism, lithemia ; in ptomain poisoning, following the eating of cer- 
tain foods, forms of fish, pork, and of fruits, especially strawberries. 

Extraneous odors and pollens from various plants, as well as 
emanations from individuals, have been known to cause asthmatic 
attacks. 

Irritating gases, vapors, and smoke will frequently bring on an 
attack. This must be due to the fact that the secretion is stimu- 
lated by the irritants from without, and in that secretion there is 
an irritant which is really the underlying etiological factor. 

The dust and vapor from the horse produces in certain individ- 
uals what is known as " horse fever," and in some instances asth- 



REFLEX NASAL NEUROSES. 211 

matic attacks are associated. This variety, I am quite sure, 
from my experience in laboratory investigations, certainly belongs 
to the altered secretion cases and is due to the ammoniac secre- 
tion. The dust from mouldy straw or any form of the grasses is 
especially irritating. 

In some asthmatic cases there is hyperplasia of the nasal 
mucous membrane, especially the middle and inferior turbinates. 
However, in many cases this is observed where there are no asth- 
matic attacks. 

Three essential elements exist in every case of asthma : A 
sensitive area of the mucous membrane, sensitive nerve-centers, 
and an internal or external exciting cause, which may occur in 
any of the above-mentioned conditions. In other words, in indi- 
viduals suffering from asthma, while there may be certain sensi- 
tive areas, and certain local predisposing causes, there must be in 
every case some systemic, underlying, etiological factor, either in 
faulty secretion or faulty elimination, or due to some organic 
structure. The nervous element may be the underlying or merely 
associated factor. The extent of involvement of the nervous sys- 
tem differs in individual cases. The pneumogastric and phrenic 
nerves, with their distributions, are frequently involved. 

Asthma can be simulated as far as breathing is concerned, and 
a perfect asthmatic attack produced by certain individuals who 
are absolutely free from any bronchial, or, in fact, any irritation 
of the upper respiratory tract, and who have never had asthma. 

In some asthmatic cases there is a change in temperature, while 
in others there are absolutely no temperature phenomena. 

The two great classifications from a pathological standpoint 
should be : 

First, the varieties of asthma in which there is, upon physical 
examination, no organic lesion, and in which the patient is in good 
health, with the exception of the asthmatic attacks. 

Second, the cases that are associated with some organic or sys- 
temic disease. 

Asthma, systemic or chemical, as is true in hay fever, must be 
worked out in individual cases. There is no one underlying etio- 
logical exciting factor of the vasomotor paresis and bronchial spasm 
which really forms the asthmatic attack. That secretion has to 
do with it is illustrated in some of the remarkable cures of asthma. 
In the so-called essential asthma, cases have been reported cured 
by the administration of diphtheria antitoxin. Care should be 
exercised, however, in selecting the cases, as antitoxin has been 
used in asthmatic cases with fatal results. This would certaiuly 
point to the chemistry of the blood and secretions ; if the theory 
of opsonins proves to be true and applicable we may be able to 
find the deficient element of the blood or the irritating exciting 



212 NASAL NEUROSES. 

factor, and by chemical process immunize the individual to these 
distressing attacks. 

Treatment.— The treatment should be directed toward— first, 
removing the peripheral irritation ; second, improving the nerve- 
centers ; and third, controlling the paroxysm. Correct any deform- 
ity. Treat any existing inflammation on lines laid down else- 
where. Cocain in 4 per cent, solution, warmed and sprayed into 
the nostrils or mopped over the surface, will obtund the terminal- 
nerve excitability. Care must be exercised in the use of this drug 
for fear of the resultant dilatation of the vessels. The irritable 
areas should be pencilled in parallel lines with a 10 per cent, solu- 
tion of chromic acid applied on a probe tightly wrapped with 
cotton, the excess of the acid being carefully removed bv another 
piece of cotton. 

For the paroxysm itself, hypodermic injection of: 

1^. Strychnine sulphatis, gr. 2V (.003) ; 

Atropine sulphatis, gr. y^ (.0004) ; 

Morphine sulphatis, gr. \ (.015). — M. 
is exceedingly beneficial. 

Or equally beneficial is : 

3^. Morphine sulphatis, gr. \-\ (.075-015) ; 

Strychnine sulphatis, gr. ■£$— ^ (.001-.0015) ; 

Hyoscine hydrobromatis, gr. -^fa (.0003). — M. 
given every third or fourth hour. 

Inhalations of stramonium leaves and saltpeter in equal parts, 
burned on a plate, maybe employed. Quebracho pushed to nausea 
and then decreased in dose may be used to advantage in some 
cases. Tonics and change of location may prove beneficial. 

Reflexes Outside of the Respiratory Tract. 

I$ar. — There are at times reflex phenomena in the ear, without 
discoverable local cause, that have been referred to intranasal irri- 
tation. Persistent and continued cough may be caused by reflex 
irritation from impacted cerumen. I have seen several cases in 
which a cough that persisted for months was entirely relieved 
by the removal of the cerumen. Earache, tinnitus aurium, audi- 
ble contraction of the tensor tympani, a condition similar to hay 
fever, described by Mackenzie, coming on periodically, in which 
there was intolerable itching, swelling, and secretion of the exter- 
nal meatus, have been described as being reflexly due to nasal dis- 
turbances. They may be due to vasomotor alterations through 
the medium of the otic ganglion. 



REFLEX NASAL NEUROSES. 213 

Eye. — Intimately connected and closely associated as are the 
nose and eve, if reflex action were found anywhere, it would be 
natural to expect it here. Notice of extension of morbid proc- 
esses from the nose to the eye, or conversely, will be taken in the 
proper place ; and only those conditions mentioned here which 
can be accounted for in no other way than by reflex action. 

Lacrimation may occur by irritation of the nasal tissue in making 
intranasal application or by the irritation set up by morbid proc- 
esses. Scintillating scotomata due to turgescence of the inferior 
turbinate have been reported by Hack. Conjunctival irritability 
with peri-ophthalmic congestion, blepharospasm and twitching of 
the eyelids have been mentioned as of reflex nasal origin. Edema 
of the lids has been cured by shrinking erectile tissue in the nose. 
A list of reflex ocular disturbances is given in order that, failing 
medication directly to the eye, thought might be taken of the 
possibility of the nose bearing a causal relation to the eye-condi- 
tion, and, having found the source, with proper treatment a cure 
might be affected. 

Asthenopia, intolerance of light, retinal hyperesthesia, muscaa 
volitantes, pain in the eyeballs, contraction of visual fields, red- 
ness of eyelids, phlyctenular ophthalmia, trophic changes of the 
cornea, and glaucoma are some of these affections. It is to be 
remembered, too, that operative procedure within the nose has 
produced similar troubles. F. R. Packard has reported a case 
of amaurosis following turbinotomy. 

Migraine, Congestive Headache, Neuralgia (Supra- 
orbital, Tic Douloureux). — Migraine or sick headache and the 
so-called congestive headaches have been cured in a large number 
of cases by intranasal treatment, and neuralgia of the various 
branches of the trigeminus has been benefited in the same way. 
Hack has gone so far as to speak of headache as turbinated 
engorgement. Attention has likewise been called to the irritabil- 
ity of the nasal mucosa occurring with the headaches of puberty. 
Neuralgia may be due reflexly to adenoids, turbinal lesions, espe- 
cially of the middle and posterior parts of the inferior turbinate, 
spurs from the septum, and intranasal synechia?. 

In epidemic influenza the patient suffers from severe neuralgic 
headaches, not only during the attack, but frequently for many 
weeks following the acute exacerbation. This is usually due 
to involvement of some of the accessory sinuses, especially the 
frontal, ethmoidal, or sphenoidal, and frequently treatment directed 
toward these structures will afford almost instant relief to the ex- 
asperating neuralgia. 

Chorea, Epilepsy, Vertigo, and Aprosexia. — Chorea 
has been reported as having been cured when such nasal condi- 
tions as rhinopharyngitis, deflections of the septum, tonsillar 
hypertrophy, or adenoids were remedied or relieved. The con- 



214 NASAL NEUROSES. 

nection between the choreiform convulsions and the irritation pro- 
duced by these intranasal conditions would appear proven when 
removal of the nasal disease causes cessation of the convulsion. 
However, this does not prove the connection, and the benefit 
derived by the removal of the nasal growth may be explained by 
the improvement in general health due to improved respiration 
and digestion, or by the alterative effect of operation per se. 

The removal of the nasal polyps, exostoses, hyperplasia?, angio- 
mata, etc., have been reported as coincident with the cessation of 
epileptic seizures. 

Vertigo has been relieved by the treatment of nasal disease, 
leaving the question open, however, as to whether the vertigo was 
purely reflex in origin or " aural " in type, due to pathologic alter- 
ations in the Eustachian tube, middle ear, etc., brought about by 
extension of the nasal condition. 

Aprosexia (inability to fix the attention, loss of memory) is 
another nasal reflex supposed to be dependent on the connection 
between the nose and the brain. 

Stomach. — Gastralgia, indigestion, flatulency, vomiting, etc., 
have been recorded as being produced reflexly by intranasal change. 
Before, however, such symptoms as these are definitely classed as 
reflexly nasal in origin, it would be advisable, with the thought 
in mind that the mucosa of the stomach and nose are continuous, to 
investigate these phenomena on this basis — that nausea, indiges- 
tion, etc., may be caused by the swallowing of nasal secretions, or 
even of air, when the nose is occluded. 

Heart. — Nasal irritation giving rise to cardiac disturbances 
has been referred to by a number of writers ; and instances of 
exophthalmic goiter benefited or cured by intranasal treatment 
have been reported by observers whose ability cannot be gain- 
said. 

Erythema, urticaria, and acne of the nose and face have 
been attributed by various authors to intranasal disturbances. 
That removal of an enlarged middle turbinate has partly, if not 
wholly, relieved a most annoying and disfiguring redness of the 
tip of the nose has been observed in a number of well-authenti- 
cated cases. The rose acne, or " red nose," is frequently found in 
elderly people and usually in individuals who indulge in overeat- 
ing and drinking. However, it may occur in the young and tem- 
perate. The entire nasal organ presents the curious tumid and 
livid purplish hue, and, owing to its conspicuous color, is a great 
source of annoyance to the individual. There is always asso- 
ciated with this' condition a turgescence of the nasal mucous mem- 
brane, more of the tumefacient or passive variety than actual 
congestion, and in many cases the parts are excessively hot, not 
only giving to the patient a sensation of heat, but actually hot by 
contact. 



REFLEX NASAL NEUROSES. 215 

While the condition so described as " red nose " presents a 
local one, yet from a standpoint of treatment the means em- 
ployed must be directed toward an underlying systemic cause. 
Such local measures as pressure by strapping the parts with ad- 
hesive plaster and depleting the nasal mucous membrane will in 
a measure ameliorate the condition, but for permanent relief the 
underlying cause must be sought and remedies directed toward 
its removal. 

Sexual Organs. — The special causes of such reflex nasal 
phenomena as sneezing, dyspnea, epistaxis, when emanating from 
the sexual organs, are continued abuse of their physiological 
function, gratified or ungratified ; the disturbances attending the 
advent of puberty, pregnancy, menopause ; chronic affections of the 
uterus and ovaries ; and all the abnormalities of menstruation. 

Treatment. — The treatment of nasal reflex neuroses should 
be first local, and, secondarily, attention should be devoted to 
restoring the unstable nerves and nerve-centers to their proper 
equilibrium by way of general systemic medication. 

Local. — Polyps, adenoids, or other growths should be removed 
by the cold-wire snare or scissors. Deflections of the septum 
should be straightened, and cartilaginous and osseous projections 
are to be sawed off. Enlargement of the middle turbinate and a 
puffiness of the vomer, if accompanied by irritability, should be 
treated by the obtuncling of the superficial nerve-endings with the 
galvanocautery lightly applied, or with chromic, nitric, or trichlor- 
acetic acid, carefully regulating the amount of tissue and depth to 
which these agents penetrate. Especial care should be exercised 
in all of these operations, lest they aggravate rather than benefit 
the existing condition. It is to be expected that for a short time 
the equilibrium of the already-disturbed nervous control should 
be still further unbalanced, but only for a time, however, to be 
followed at an interval regulated by the severity of each individual 
case by the desired amelioration or cure. 

General. — Each case should be carefully studied on its own 
merits, and the physician should not despair if the desired result 
is not rapidly obtained. 

As a general tonic, the following, given in pill or capsule three 
times a day after meals, will be found advantageous : 

fy. Strychnine nitratis, gr. ^-gr. -^ (.0015-.003) ; 

Acidi arseniosi, gr. ^q— gr. ^ (.001-0015); 

Ferri redact!, gr. ^-gr. \ (.015-03); 

Quininse hydrobromatis, gr. j-gr. iij (.06-18) ; 

Pepsini saccharati, gr. iij (.18). — M. 

Or the following pill, which is a modified form of that recom- 
mended by John N. Mackenzie, to be taken before meals : 



216 NASAL NEUBOSES. 

Ify. Zinci phosphidi, gr. -^ (.004) ; 

Quininse bromidi, gr. ij (.12) ; 

Extracti nucis vomicae, gr. i (.015). — M. 

If there is tendency to constipation, there should be added \ 
to J grain of the powdered extract of cascara sagrada. Shower 
baths, cold or tepid, or local sponging with cold water and alcohol 
should be ordered. Nutritious diet and an outdoor life are to be 
insisted unon as far as practicable. 



CHAPTER IX. 

NONINFLAMMATORY DISEASES OF THE ANTERIOR 
NASAL CAVITIES. 

EPISTAXIS. 

Varieties as to cause : (1) Trauma ; (2) Local nasal lesions ; 
(3) Constitutional conditions ; (4) Vicarious. 

Definition. — Hemorrhage from the mucous membraue of the 
nose. 

Synonyms. — Bleeding from the nose ; Hemorrhagia narium ; 
Nose-bleed ; Rhinorrhagia. 

Etiology. — Epistaxis has been said " to take place as a symp- 
tom, as a disease, and as a physiological process." In general, it 
occurs more frequently in males — owing probably to their more 
exposed life — than in females, and is most frequent between the 
second year of life and puberty. No age can be said, however, to 
be exempt from its occurrence. The conditions in which it is 
present are many and widely varied. We may simplify a consid- 
eration of these in their etiological relationship by classifying them 
into four divisions. Thus we may consider epistaxis as caused 
by trauma, as attending local nasal lesions, as present in constitu- 
tional conditions, and as the vicarious performance of a suspended 
process elsewhere. Neurasthenic individuals frequently suffer from 
nose-bleed. This is especially true in the fat, flabby neurasthenic. 
The nasal mucous membrane tends to passive congestion, espe- 
cially over the erectile tissue of the turbinals, and there is fre- 
quent bleeding. 

1. Traumata. — Perhaps the most frequent of these are blows 
upon the external nose, received during a fist-fight, from colliding 
with beams or with an open door, from falls, recoil of a gun, and 
a host of similar exhibitions of mechanical violence, or from 
fractured skull. Abrasions or cuts of the mucous membrane, 
whether accidental, as by puncture with a fork, pencil, or other 
sharp-pointed instrument entering through the nares or pene- 
trating through the integument, or instrumental, either at the 
site of operative procedures or from careless handling in exam- 
inations and topical applications, are frequent causes. The in- 
troduction of foreign bodies into the nose, as frequently done 
by children in play, is often attended by hemorrhage more or 
less severe. The same is true of the wounds produced by pick- 

217 



218 NON-INFLAMMATORY DISEASES, ETC. 

ing the nose in various nasal irritations, or in the removal of 
crusts — a practice not limited to those of younger years. Cer- 
tain occupations have a greater or less predisposing influence, as 
they involve the inhalation of mechanical irritants. These include 
steel-grinding, stone-dressing, and the like. The same is true of 
occupations involving the inhalation of acrid fumes, such as strong 
ammonia, and various chemical and medicinal substances. Rarely, 
epistaxis may follow the violent rupture of hematomata. 

2. Local Causative Agents. — The various local hyperemic 
conditions by their very nature markedly predispose to epistaxis. 
The hyperemia associated with the early stages of acute rhinitis, 
that due to the strongly overacting heart of the athlete or hard- 
working laborer, and that occurring in the general filling out of 
the bodily structure during pubescence, may be cited as examples, 
and the epistaxis may in a certain sense be regarded as a natural 
relief measure. Some trace a causative influence in a nasal hyper- 
emia from natural or unnatural use of the sexual apparatus. 
Ulcerative processes, however widely varied as to origin, are 
notably active in producing a bloody discharge. Especially is 
this true of. the ulceration attending the more rapid malignant 
growths. Foreign bodies not infrequently cause a hemorrhage 
from the hyperemia following their continued presence as irritants, 
from actual abrasions, or from superficial necrosis of the contigu- 
ous membrane, with exposure and erosion of the smaller blood- 
vessels. In some cases these bodies may be animate, as maggots 
and various forms of worms, and more or less wounding of the 
membrane by their movement and the harder portions of their 
external structure may be the cause. Certain of the neoplastic 
growths of the nose, such as the angiomata, sarcomata, and car- 
cinomata, are also attended with varying hemorrhage. Polypoid 
growths frequently are accompanied by a blood-streaked discharge, 
and the same condition frequently attends adenoid vegetations. 
Hay fever is often marked by a discharge tinged with blood. 
Malformations — especially of the septum — such as spurs, exos- 
toses, and deviations, predispose in no slight degree, both by the 
alteration in air-currents and by the thinning of the membrane at 
the variously sharpened angles, with subsequently lessened pro- 
tective backing for the delicate vessels. It is apt to occur with 
little provocation in simple chronic and atrophic conditions of the 
nasal mucosa. Epistaxis may also occur where there is engorge- 
ment of the ethmoidal veins. 

3. Constitutional Conditions Favoring" Epistaxis. — The list 
of these is a long one, and nasal hemorrhage occurs with trifling 
or grave import. Of these, we may fittingly first mention the 
hemorrhagic diathesis, hemophilia or bleeder's disease, which not 
infrequently first exhibits its presence by the copious and intract- 
able nasal hemorrhage that may appear on trifling provocation. It 



EPISTAXIS. 219 

occurs on exposure to the sun, during the onset of typhoid fever, 
and at various times during the eruptive fevers. Pneumonia, diph- 
theria, relapsing fever, gout, ephemeral fever, influenza, scurvy, pur- 
pura, the various anemias, bronchitis, emphysema, and the specific 
inflammations, especially syphilis, tuberculosis, and leprosy, may be 
marked by its occurrence. Congestive conditions of the membrane 
due to cardiac lesions, such as insufficiency of the right side of the 
heart, are apt to And relief in escape of blood from the nose. The 
same is true of the cyanotic conditions from portal obstruction, as 
in acute yellow atrophy of the liver, the varying cirrhoses of that 
organ, or pressure from neighboring tumors or enlarged organs. 
Similar conditions may attend Bright's disease. iSor must con- 
gestions caused by more local processes be overlooked, as that 
following pressure upon the return channels of the neck by tumors, 
notably a bronchocele, or by too tight constriction from ill-fitting 
neckwear. The general hyperemia- seen in plethora may find oft- 
times a partial relief in a nasal hemorrhage, and we have already 
mentioned the hyperemia of the overacting heart. Alcoholism is 
peculiarly liable to develop attacks of nose-bleed, and the athe- 
roma of old age, through structural change in the vascular system, 
decidedly predisposes. Apoplexy may in some cases be heralded 
by a slight epistaxis, and it may occur as a natural relief during 
the attack. Similarly, congestions of the cerebral vessels during 
prolonged or severe mental effort may be partially relieved by a 
flow of blood from the nose. Atmospheric conditions play a very 
decided part in certain cases, from the disturbance betAveen intra- 
and extra vascular pressures which they cause. This explains the 
copious nose-bleeding so often seen in a rapid ascent to higher 
altitudes and lessened atmospheric pressures, examples of which 
exist in those climbing high mountain-peaks, in those making 
balloon-ascents, and in the workers in caissons or deep mines. 
Lastly, we may mention certain drugs whose ingestion in full 
amounts or in toxic doses may be attended with epistaxis. Such 
a list would include phosphorus, chloralamid, and the various 
compounds of the salicyl group. 

4. Vicarious Epistaxis. — The site of vicarious menstruation 
is in a large proportion of cases the nasal mucosa, and sudden 
cessation of a flow of blood from hemorrhoids is apt to be replaced 
by epistaxis. 

As will be seen, epistaxis occurs in many conditions, and its 
significance is usually evident. In many of the cases, the severity 
of the attendant process accounts for the physical conditions neces- 
sary to permit the escape of blood. In others, an active and 
energetic immediate cause is necessary, and this is usually fur- 
nished by a severe sneeze, cough, or violent blowing of the nose. 

Pathology. — The anatomical features are of importance in 
this connection. The blood-vessels of the pituitary membrane, it 



220 NON-INFLAMMATORY DISEASES, ETC. 

will be remembered, are lacking in muscular backing, and are 
more or less intimately related to the bony or cartilaginous for- 
mations underneath. This condition furnishes a firm counter- 
resistance which does not permit the vessel to avoid or mitigate 
force from without by sinking into the softer bed that muscular 
tissue would furnish, nor does it afford the aid of muscular con- 
traction in closing a wound, or in retraction of severed blood- 
vessel ends. The site of the hemorrhage may be any part of the 
mucous membrane. Certain locations are, however, especially lia- 
ble, and one in particular, the so-called " site of predilection," at 
the anterior inferior part of the septum, which has been so named 
from the relative frequency of occurrence there. Macroscopically, 
the membrane may be swollen and red, it may show varicosities 
or erosions, or there may be a clean, sharp cut. It may be the 
margins of a septal perforation that supply the points of escape, 
or the ragged edges of a ruptured cyst. On inspection the hem- 
orrhage may be seen in the form of an arterial spurt, a slower 
welling-out of blood, or a slow, steady capillary oozing. Micro- 
scopically, the lesion is either an overdistention of the blood- 
vessels, with paresis, leakage of blood into the submucous tissue, 
and subsequent escape upon the surface, or a rupture or wound of 
the vessel-walls, with exit upon the surface. The hemorrhage 
tends usually to stop spontaneously, and this generally is brought 
about by the formation of parietal thrombi. Dislodgement of 
these is a common cause of secondary hemorrhage. Following a 
profuse escape of blood, the membrane not uncommonly is pale 
and anemic, returning soon, however, to its normal state. Not all 
the cases of epistaxis must be regarded as of pathological import, 
as the process is in some instances evidently natural and physio- 
logical, and is nature's method of blood-letting. This is true of 
plethora, and the various renal, hepatic, and cardiac congestions. 

Symptoms. — The dominant symptom is, of course, loss of 
blood through the nose. If the lesion be in the anterior part of 
the nose, it escapes through the anterior nares ; if in the posterior 
regions or if the patient be recumbent, it has exit through the 
choanee into the pharynx, and, from swallowing or entrance into 
the bronchial and pulmonary tracts, the subsequent ejection may 
simulate hematemesis or hemoptysis. The amount of blood lost 
varies greatly. It may be a persistent and profuse flow, or it may be 
a slight escape, barely tinging the nasal secretion. The attacks may 
be irregular and isolated, they may occur with periods of varying 
quiescence or as daily outbreaks, and the flow may last from a few 
minutes to several hours. Usually the blood shows a ready ten- 
dency to coagulate, but such, however, is not the case in hemo- 
philia. Premonitory symptoms may precede the attack, such as 
congestive headache, fulness, roaring in the ears, vertigo, and dis- 
turbances of vision. In many cases, the first intimation of the 



EPISTAXIS. 221 

hemorrhage is a bubbling of inspired air through the fluid blood in 
the nasal space or spaces, or the discoloration of the handkerchief 
used to relieve a supposedly profuse discharge of secretion. The 
symptoms following the epistaxis vary greatly, and are severe pro- 
portionately to the amount of blood lost. There may be, and fre- 
quently is, a sense of absolute relief. The head feels clear and 
the brain is active, respiration is easier, and the heart free and 
less laboring in its action. The congestive symptoms, if present 
before, are now abated. On the other hand, headache may follow, 
or a moderate epistaxis in a healthy person may cause little or no 
after-effect. If profuse, however, all the symptoms of exsanguin- 
ation and syncope may rapidly supervene. The bleeding may 
take place from one side, or it may occur from both. Traumata 
usually cause one-sided hemorrhage, and the majority of the local 
affections do the same. The constitutional causes and the vica- 
rious manifestations are, however, almost always from both nares. 
Inspection, as a rule, either by anterior or posterior rhinoscopy, 
will reveal the site of the process, and stress is laid by some 
authors upon a brownish stain observed between periodical attacks 
as indicating the site of escape. 

Diagnosis. — The diagnosis of epistaxis is usually not diffi- 
cult, but may frequently require anterior or posterior rhinoscopy 
for a sure recognition of the trouble. Hemorrhages from local 
lesions are generally unilateral, while those from the stomach, 
pharynx, tongue, lungs, and fractures at the base of the skull, if 
passing through the nose, are generally bilateral if the spaces are 
both clear. Moreover, in the latter class of cases there is usually 
a history of greater or less diagnostic import. Hemorrhage from 
the posterior and inferior part of the septum may be misleading. 
Bleeding from one or more of the accessory sinuses may be 
extremely difficult to differentiate. Inspection, however, showing 
exit of blood at or near the sinus-outlets, should be suspiciously 
regarded, but little dependence can be placed upon the character 
of the blood in given cases. 

Prognosis. — The prognosis in the majority of cases is good, 
and in itself the nasal hemorrhage is rarely fatal. In nasal dis- 
ease, excepting when due to malignant growths, the outlook is 
favorable. In the systemic conditions, the prognosis depends upon 
the amenability of the disease to treatment. Diathetic conditions, 
especially hemophilia, present largely a bad forecast, and the same 
is true of chronic heart disease. In plethora the outlook is good ; 
the blood lost in an attack is usually soon re-formed. 

Complications. — Syncope occurs in some cases, not alone as 
a result of blood-loss, but as the expression of the nervous shock 
which sensitive people sometimes experience at the sight of blood. 

Treatment. — The constitutional derangements with which 
epistaxis is associated, it is needless to say, must receive their 



222 NON-INFLAMMATORY DISEASES, ETC. 

proper treatment, and usually with their subsidence the cessation 
of the attacks of epistaxis occurs. Foreign bodies, both animate 
and inanimate, must be removed. In many cases no treatment is 
necessary, the hemorrhage subsiding spontaneously. Other cases 
require local measures of greater or less severity. Moderately 
severe attacks may cease with simple digital pressure on the nasal 
alee, or on the application of ice to the nose, to the forehead, or to 
the nape of the neck, or by insufflation of iced water or hot water. 
Insufflation of finely powdered alum, or tannic acid, or 8 to 10 
per cent, solutions of the same drug may be used. Solutions of 
zinc sulphate, acetate of lead, or sulphate of copper, in the propor- 
tions of 30 grains to the ounce of water, may be applied by syringe 
or on pledgets. Cocain in weak solutions has been recommended, 
but is open to the danger of absorption causing toxic effect from 
the open surface, and to the subsequent reactionary hyperemia it 
causes. In many cases the bleeding can be controlled by supra- 
renal extract or adrenalin chloride applied to the bleeding area on 
pledgets of cotton. Ulcerated spots may be touched carefully by 
a 15 per cent, solution of chromic acid, avoiding the adjacent 
tissue in the application. Collodium applied over the bleeding 
surface, whether it be ulcerative, traumatic, or surgical, as 
recommended by Richardson, will frequently arrest the bleed- 
ing. The actual or galvanocautery is recommended by some. 
In other cases digital compression of the facial artery may 
be found to be effective, and a recumbent posture, with 
arms extended over the head, favors cessation of the flow. 
At the same time, the internal administration of certain drugs 
may be employed, such as tincture of ergot, in 10-minim 
doses every two or three hours, or the oil of erigeron ; 5- to 
10-drop doses of dilute sulphuric or nitric acid every hour for 
three doses may be tried, or tincture of opium, in 5- to 8-minim 
doses every three hours to an adult, avoiding its use in children. 
These methods failing, resource must be had to various methods 
of local pressure, with or without the use of styptic solutions. 
Thus the spaces may be filled with plugs of wool, lint, or absorbent 
cotton, which should be aseptic, and may be plain or medicated. 
An 8 per cent, solution of antipyrin is admirable, as are the solu- 
tions already mentioned. The plugs may be prepared by soaking 
and then drying, and thus prepared may be kept on hand until 
needed ; when they are to be used, simply wet them with plain 
water, or they may be freshly prepared. Fresh solutions of a 15 
volume strength of peroxid of hydrogen, dilute solutions of hamam- 
elis, or 1 : 1000 solution of trichloracetic acid are excellent. It 
is advisable to attach a fine but strong cord to each pledget to 
facilitate removal. These are inserted through the anterior nares, 
and packed one by one carefully to insure equable pressure. Vari- 
ous forms of rubber bags have been introduced, which, inserted 



EPISTAXI& 223 

empty, may afterward be inflated, and have more or less prac- 
tical value ; or as a last resort, the posterior and anterior nares 
may both be plugged, using a Bellocq cannula or a soft gum 
catheter. In one case of the author's, a polyp snare gave good 
results. The instrument is passed through the passage and out 
into the pharynx, where it is seized and drawn forward enough to 
fasten the attached strings to a dossil of size sufficient to half-fill 
the space. The instrument is then withdrawn, bringing with it 
the strings, and by traction on these the dossil is brought firmly 
up to and within the choana?, completely occluding them. The 
strings are left in the space, the anterior nares are plugged, and 
the strings are fastened by tying in the anterior plug or by tying 
around the head. This gives a space between the two plugs, which 
fills with blood, the pressure gradually equalizes, and clotting and 
occlusion of the points of exit take place. In packing the nasal 
spaces, care must be taken not to pack so tightly as to cause any 
danger of devitalization of the membrane from inhibition of the 
blood-supply. Xor in any case should the plug be left in longer 
than is necessary to insure formation of a firm clot, as in more 
than one reported case grave pyemic symptoms have followed sup- 
puration behind a pledget too tightly packed to allow exit of the 
pus, and kept in place long enough to allow it to form. Forty- 
eight hours should be the extreme limit for their retention. After 
their removal the nose should be carefully cleansed by mild solu- 
tions to detach and bring away the blood-clots, and the patient 
carefully watched for some time, and enjoined to avoid violent 
exercise for several days to prevent recurrence of the trouble. 
Bpistaxis Occurring' in Bleeders (Hemophiliacs). — While 
packing the nostril may fail to arrest the hemorrhage, yet suffi- 
cient cotton should be put in the nose to prevent nasal breathing, 
as in cases in which the oozing is very slight the suction produced 
by breathing is sufficient to keep up the bleeding. Blocking of 
the nostril will prevent this suction. In many cases where the 
arterial pressure is low, large closes of nitrate of strychnin are 
highly beneficial. The internal administration of powdered opium 
(1 gr.) with acetate of lead (l gr.) repeated every hour for three 
doses will, on account of its tendency to increase the coagula- 
bility of the blood, arrest the bleeding in many cases. 



CHAPTER X. 
FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIESc 

1. Inanimate. 

a. Rhinoliths. 
6. Miscellaneous. 

2. Animate. 

a. Parasites. 

INANIMATE. 

Rhinoliths. 

Definition. — A foreign body formed within the nasal space 
by the deposition of mineral salts ; in most, if not all, cases there 
is a nucleus of some character as a basis for deposition. 

Synonyms. — Nasal calculi ; Nasal concretions. 

Etiology. — The causation of rhinolith-formation is usually 
referred to two underlying conditions : First, alteration in the 
quality of the nasal secretion ; second, the existence of conditions 
favoring its retention. The gouty diathesis has been advanced as 
an etiological factor and has received several supporters. Rhi- 
noliths usually are found in adults, and more females than males 
seem to be affected. 

Pathology. — The pathology of rhinolithic formation, other 
than that it represents an excess of suspended mineral matter in 
the nasal secretion, is unknown. The pathology of the morbid 
process it finally causes, if not removed, is identical with that of 
any other foreign body in the same location, and need not receive 
repetition here. 

Site. — Any portion of the nasal space may be the site of their 
formation, although they are usually found in the lower meatus. 

Characteristics. — Rhinoliths are usually single, though cases 
of double occurrence are reported, not, however, involving more 
than one nostril, and usually linked. In weight and size they 
present wide differences, from small bits of a grain or so to the 
enormous mass reported as weighing 720 grains. In shape they 
are widely variant, the portion of the nasal space in which they 
originate being regarded usually as exercising a determinant influ- 
ence in that respect. The surface is comparatively rough or cor- 
rugated, or may be rather smooth. The color varies from a dirty- 

224 



BHINOLITHS. 225 

white to a gray, brown, black, or greenish tinge. In consistence 
they may be soft and crumbling, or grow through different degrees 
of hardness to a formation firm and hard in texture. The outside 
may be firm and dense and the inside soft and crumbling. Chem- 
ically, they are largely salts of calcium and magnesium, principally 
the carbonates and the phosphates, with traces of the chlorid and 
carbonate of sodium. Some organic matter is usually intermixed 
in the substance. Usually, they exhibit the typical structure of a 
calculus, being formed of concentric lamella; of earthy matter dis- 
posed about a nucleus. The latter may be of almost any character. 
In some cases, the rhinolith has been found without a nucleus, but 
with a hollow, soft, or gelatinous center ; in others, there is seen 
neither nucleus nor peculiar center, the nucleus apparently being a 
flake of encrusting mineral deposit, or so small as to be practically 
invisible. From this circumstance has arisen a discussion as to 
whether rhinoliths may or may not be of two varieties — one in 
which there is no nucleus for deposition of the mineral salts, and 
another variety in which the nucleus is present and becomes 
gradually encased in the succeeding earthy coverings. Whichever 
view is correct, it certainly is a fact that the formations with a 
demonstrable nucleus are of far greater number. 

Symptoms. — Rhinoliths during their formation give rise usu- 
ally to no symptoms, except it may be those of increasing nasal 
obstruction. They are, however, foreign bodies, and, as they 
increase in size, the symptoms of a foreign body impacted in the 
nasal space gradually develop. Having already considered these 
elsewhere, we need not repeat them here. 

Diagnosis. — The diagnosis is made by inspection after cleans- 
ing the space with an alkaline wash, by exploration with a probe, 
and by the history. A calculus may not unlikely be mistaken for 
a polypus ; the touch of the latter is, however, different. The 
rough presenting part may look and feel to the probe like necrosed 
bone, but has not the stench of the latter, and the history is 
different. 

Prognosis. — The prognosis is practically that for any foreign 
body in the same location. 

Treatment. — The rhinolith, as well as other foreign bodies, 
can often be easily syringed out ; but when encysted, after freeing 
the foreign body it can be removed by instrumental means, the 
instrument employed being the one best adapted to the individual 
case. The instruments shown in Figs. 65 and 66 are suitable for 
such cases. 

The rhinolith may be crushed and then removed by syringing. 
The nostril should be carefully cleansed twice daily by an anti- 
septic alkaline wash until all symptoms of irritation disappear. 

15 



226 FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIES. 



Miscellaneous. 

The list of reported inanimate foreign objects which have been 
found within the narrow confines of the nasal spaces is amazing, 
both as to its length and the wide variety of articles which it com- 
prises. It is useless here to attempt even a brief mention of such 
objects, save to remark that size is practically their only limi- 
tation. We are considering, of course, only the cases in which 
such objects after entrance to the nasal spaces become lodged, and, 
finally, after successfully resisting attempts of the patient at their 
removal, are brought, it may be after the lapse of years from their 
insertion, to the physician's attention. 

Etiology. — Foreign bodies of this class may enter the nasal 
spaces in three important ways. They may be inserted directly 
into the nose by the patient. This is more frequent in children, 
in those of unsound mind, and in that strange class of morbid 
entities — malingerers. Secondly, they may enter the nasal spaces 
through the choanse. This occurs usually in vomiting or choking, 
in which swallowed substances are forcibly ejected and pass behind 
the soft palate. Paralysis of this organ markedly predisposes to 
this method of entrance, even in deglutition. A very few cases of 
instrumental introduction are recorded. Thirdly, though this is 
rarely the case, they may find entrance through penetration of 
the nasal walls or floor of the nasal hood. We may also mention, 
as a foreign body of local production, the so-called rhinoliths or 
nasal calculi, which have just been considered (page 224). 

Pathology. — The pathology varies greatly with the nature 
of the object. The object may be small, so situated and of such 
a character as to evoke practically no manifestations from the 
membrane, save a somewhat greater irritability to external influ- 
ences or an increase in the normal secretion of the adjacent 
glands. On the other hand, with varying degrees intervening, the 
opposite extreme may occur. The object at once, or perhaps after 
years of quiescence, causes an acute inflammation by its irritation. 
The membrane becomes swollen and turgid, and its vessels become 
dilated. The submucosa becomes infiltrated with fluid and cellu- 
lar elements, and the glands adjacent to the object are spurred to 
greater secretion. The swelling continuing, the pressure gradu- 
ally increases, helped, it may be, by swelling of the object itself, 
if it be of such a character, and acts as a cut-off to the supply 
of nutriment. As a result, the epithelium dependent upon this 
undergoes necrotic changes, desquamates, and exposes the under- 
lying boggy tissue. Pyogenic infection occurs, attempts at cell- 
proliferation and organization are counterbalanced by the liquefy- 
ing action of the pyogenic organisms, and superficial necrosis takes 
place, forming irregular ulcerated areas. If, now, from adjacent 
vessels not so directly influenced by the pressure, sufficient nutri- 



MISCELLANEOUS FOREIGN BODIES. 227 

ment is obtained by budding, granulation-tissue may be formed, 
embedding, as it were, the object in a nest of granulations. If 
the pressure continues, the necrosis and infection may extend 
deeper, even to perforation of the septum, the nasal floor, or the 
lateral wall, and discharge of the irritating medium follow. This, 
however, is rarely the case, and the foreign body, before advan- 
cing beyond the formation of ulcers, usually causes such annoyance 
or even pain as to compel the sufferer to seek a physician for its 
removal. Coincident with the inflammatory process, the increased 
secretion, dammed back by the nasal obstruction, becomes infected 
both by putrefactive organisms which give rise to an evil smell, 
and by principles it contains irritant to the membrane, thus 
increasing or helping to maintain the inflammation. Slight epis- 
taxis may follow rupture of vascular twigs. After removal of the 
object, and under appropriate medication and protection, the mem- 
brane gradually returns to a condition more or less normal, depend- 
ing in each particular case upon the extent of the tissue-loss or 
-change. 

Symptoms. — These, as will readily be seen, must vary in 
accordance with the character of the foreign element. A small 
smooth object may cause no inconvenience at the time of intro- 
duction, and be practically forgotten so far as its presence is a 
source of annoyance. Quite large bodies have lain in the nasal 
spaces for years, giving no annoyance by their presence, and then 
suddenly causing severe inflammatory phenomena. On the other 
hand, the inflammation may begin immediately after the object is 
inserted. In either case, the symptoms are those of irritation and 
obstruction. The essential features of a fairly severe case are, 
briefly, as follows : 

The membrane of the affected side becomes swollen and pain- 
ful ; the discharge increases, at first glairy, later mucoid ; finally, 
purulent, and often offensive. Not infrequently it is streaked with 
blood, and, excepting in severe cases with septal perforation, uni- 
lateral, and may or may not excoriate the nostril and lip. Obstruc- 
tion of the affected side is marked and annoying, affecting the 
respiration and giving the voice a nasal twang. The ala may 
participate in the inflammation and become red and swollen. Pain 
of a neuralgic character in the nose, cheek, and head may be 
present, and various sympathetic disturbances of the eye and ear, 
such as increased secretion, tinnitus, and otalgia. Attacks of 
sneezing may occur, vertigo, possibly nausea and vomiting, and in 
one very severe case reported there was a unilateral facial hyper- 
idrosis of the same side. On inspection, for which cleansing by 
an alkaline wash may be necessary, the membrane will be found 
swollen and congested, possibly hiding the object. This, however, 
may be visible, and in cases of long standing may be seen sur- 
rounded by granulation-tissue, giving an appearance not unlike 



228 FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIES 

that of cancer or other malignant process. A curious case is 
recorded in which a bean in the nasal space underwent germina- 
tion, the true nature of the trouble not being discovered until an 
attempt was made to remove the sprouts, which had been mis- 
taken for polypi. The site of the body may vary, and it may 
take almost any portion of the nasal space for its lodgement. 
Anteriorly, however, impaction usually takes place in the inferior 
turbinate and the septum. 

Diagnosis. — Usually this is not difficult. The history, uni- 
lateral discharge and its character, inspection, and the use of the 
probe form the essential elements. 

Prognosis. — The outlook is good. Recovery rapidly takes 
place, as a rule, after the removal of the foreign element. If 
untreated, however, the case runs a slow chronic course, the dis- 
charge never wholly ceasing, and the duration being marked by 
exacerbations such as we have described. 

Treatment. — For the removal of the foreign body, the forceps 
shown in Figs. 65 and 66 , are of the best ; however, the size, 
shape, and location of the foreign body will often necessitate the 
use of a special instrument adapted to the case. The after-treat- 
ment should be palliative. After cleansing the nostril with a 
warm boric-acid solution, 10 grains to the ounce, there should 
be applied twice daily to the irritated surface the following : 

1^. Camphorse, gr. j (0.06); 

Thymol, ' gr. j (0.06) ; 
Menthol, gr. ij (0.12) ; 

Cosmolin (liquid), flsj (30.).— M. 

ANIMATE. 

It not infrequently happens that the nasal passages are invaded 
by various lower forms of life. Such reported cases include vari- 
ous insects, intestinal worms, leeches, and the like. These, as a 
rule, quickly give evidence of their presence by the itching, 
increased discharge and pain, which they cause through their 
presence and movements. As a rule, they are quickly recognized 
and as readily removed, living or dead, unless they unfortunately 
have penetrated the connected sinuses. To enter into a detailed 
account of these is scarcely necessary. There is, however, a phase 
of this condition, fortunately rare in northern latitudes, but which 
is of sufficiently common occurrence in tropical climates to demand 
attention. This is the condition produced by the development 
within the nasal structures of the larvae of certain flies, and which 
is termed myasis narium, or, in vulgar English phrase, " maggots 
in the nose." 

Etiology. — The direct cause of this condition is the deposi- 



ANIMATE FOREIGN BODIES. 



229 



tion of the ova within the nasal space, or spaces, and the hatching 
of the larvae under the favoring conditions present. Several 
varieties of flies have been proven responsible, and it seems more 
than probable that the eggs are deposited directly by the female, 
either within or at the margin of the anterior nares. Some observ- 
ers, however, have claimed that the eggs are taken into the nose 
during the act of smelling various substances which have harbored 
them. The condition is rare in temperate or cooler climates, 
though isolated cases have occurred, but is more prevalent, even 
quite common, in the tropical countries, especially South America 
and India. The favoring local conditions seem to be those 
attended with a fetid secretion, explainable by the instinct of the 





Fig. 65.— Forceps for foreign bodies. 



Fig. 66.- 



-Forceps for foreign bodies in the 
nose. 



insect to deposit its eggs in putrid surroundings. It is even 
claimed by some that a healthy membrane is never affected in this 
manner. Patent conditions of the nostrils and the passages, as in 
atrophic changes, are also to be considered as favorable. The 
term " peenash," as used in India to designate the disease, seems 
to be a rather vague term, comparable possibly to the loose manner 
in which ozena is used in English. 

Pathology. — The presence of the larva?, of course, excites 
a catarrhal inflammation. This, however, is but a brief prelude 
to the ravages caused by their voracious activity. The mem- 
brane is attacked, as it were, "tooth and nail," and rapidly 
pulpified. If the larvae are not removed, the structures immedi- 
ately investing the bone and cartilage are quickly destroyed, and 
caries of the bone immediately follows. Suppuration is inevitable, 



230 FOREIGN BODIES IN THE ANTERIOR NASAL CAVITIES. 

and takes place not alone at the site of larval activity, but spreads 
widely as the germs gain ready entrance to the connective-tissue 
spaces. The larvae not infrequently burrow out through the nasal 
walls, and, forming swellings not unlike abscesses in character, 
finally eat through the integument and escape. They may burrow 
through into the bony sinuses, or even into the cranial cavity. 
The ethmoid, sphenoid, palate, and even the superior maxillary 
bones may be totally destroyed, and inflammation of the meninges 
is almost sure to follow in fatal cases. 

Symptoms. — The symptoms are severe and rapid in course. 
The entrance of the fly may or may not have been noticed. The 
incubation-period of the ova being, however, short, within a day 
or so after their deposition there is a sense of uneasiness in the 
nose, a slightly increased discharge, and a slight tickling. This 
last symptom rapidly increases, and attacks of violent sneezing 
succeed, and, shortly, as the larvae develop and increase in num- 
bers, the tickling develops into formication, which, by its per- 
sistency, is almost unbearable to the patient. Pain is present, 
severe and persistent, over the frontal, occipital, or vertical regions, 
and severe throbbing headaches, all so constant and severe as to 
cause insomnia of a dangerous type in itself. The nasal discharge 
is early increased, and gradually becomes thicker and purulent, 
containing the pulpified tissue, and possibly also, in varying num- 
bers, the maggots themselves. Epistaxis is frequent, from a small 
tinge to a dangerous burst of blood. Edema of the face and eye- 
lids, possibly also of the palate, is likely to follow, and small 
tumors not unlike abscesses in character are apt to form, each 
tending to open on the surface and discharge its contained larvae 
with the mass of putrid material in which it is embedded. Unless 
relief is obtained, the loss of tissue is rapid and extensive. The 
mucous membrane is pulpified and discharged ; the bones and the 
cartilage, owing to loss of nutriment from the supply furnished by 
vessels from the already-destroyed softer structures, perhaps also 
directly attacked by the larvae, are necrosed, and come away in 
the foul discharge. The bony and cartilaginous framework of the 
nose, in whole or part, may be destroyed, with not infrequently 
fatal or terribly disfiguring results ensuing. It is scarcely neces- 
sary to speak of the profound systemic involvement that rapidly 
develops. All the evidences of a septic intoxication of no mild 
degree quickly come on — high and irregular fever, chills and 
sweats, gastric disturbances, in short, a typical case of pus-intoxi- 
cation. As the disease progresses, the symptoms of greater local 
action become more marked — vertigo, sudden spells of temporary 
blindness, agonizing headache, and maniacal delirium. Indeed, 
suicide is not unlikely to be attempted to escape the frightful 
agony. Finally, from the septic intoxication or an acute menin- 
gitis, the death of the patient takes place in convulsions and coma. 



ANIMATE FOREIGN BODIES. 231 

Diagnosis. — The absolute diagnosis is, of course, made by 
the discovery of the maggots either in the discharge or in the 
nose itself. There may or may not be sufficient history to be of 
assistance. The rapid course, severity of symptoms, and char- 
acteristic purification of the tissue are all points of essential 
interest. 

Prognosis. — The prognosis depends entirely upon the extent 
of tissue-loss and the accessibility of the maggots for the applica- 
tion of local anthelmintics. Cases early recognized, of easy access, 
and properly treated, offer a good outlook. On the other hand, 
cases recognized late, with extensive and increasing tissue-loss and 
suppuration, sinuses filled with the larvae and not accessible to 
treatment, offer an extremely grave prognosis. The possibility of 
suicide must be borne in mind. 

Treatment. — The use of chloroform-injections seems to have 
met universal approval, and to have superseded solutions of tur- 
pentine, tobacco, and various astringents and anthelmintics. This 
drug may be used pure or mixed with equal bulk of water, before 
separation takes place between the two, or even by inhalation. 
The injection is, however, painful, and a general anesthetic, pref- 
erably chloroform itself, had better be used before the injection 
is made. The procedure quickly kills the larvae, after which they 
should be .removed, and the cavities cleansed by hydrogen-peroxid 
injection ; if ulceration is present, the area should be touched with 3 
per cent, chlorid-of-zinc solution for its stimulating effect ; if much 
irritation is present, it may be relieved by application night and 
morning of an ointment : 

1^. Acetanilid, gr. v (.3) ; 

Salol, gr. iv (.24) ; 

Menthol, gr. v (.3) ; 

Unguenti petrolati, 

Unguenti zinci oxidi, da 3iv(15.).— M. 

If, however, the maggots are present in the various sinuses, opera- 
tive procedures in order to reach and dislodge them must almost 
invariably be undertaken. 



CHAPTEE XI. 

NEOPLASMS OF THE RESPIRATORY TRACT. 

Classification. 
Non-malignant : 

Origin. — Blastodermic layer— hypoplastic and epiblastic layers 
Epithelial-tissue type — adult variety (typical, benign). 

1. Papilloma. 

2. Adenoma. 

Origin. — Blastodermic layer — mesoblastic layer. 
Connective-tissue type — adult variety (typical, benign). 

1. Angioma and Hematoma. 

2. Chondroma (Enchondroma). 
3.* Exostosis, 





4. Fibroma. 




5. Lipoma. 




6. Osteoma. 




a. Eburnated. 




b. Cancellated. 




7. Myxoma (Polyp). 




a. Myxofibroma. 




b. Mucocele. 




c. Cystic. 


Malignant : 





Origin. — Blastodermic layer — hypoblastic and epiblastic layers. 
Epithelial-tissue type — embryonic variety (atypical, malignant). 
1. Carcinoma. 

a. Epithelioma. 

1. Squamous-celled. 

2. Cylindrical-celled. 

3. Tubulated. 

b. Glandular. 

1. Scirrhous. 

2. Encephaloid. 
Origin. — Blastodermic layer — mesoblastic layer. 
Connective-tissue type— embryonic variety (atypical, malignant). 

1. Sarcoma. 

a. Round-celled, small and large. 

b. Spindle-celled, small and large. 

c. Mixed-celled. 

d. Giant or myeloid. 

e. Alveolar. 
Mixed tumors. 

1. Adenocarcinoma. 

2. Myxocarcinoma. 

3. Myxosarcoma. 

4. Myxofibroma. 

5. Teratoma. 



Cysts. 



1. Simple or Retention-cysts. 

2. Cystoma. 

3. Dermoid cysts. 



232 



CLASSIFICATION OF NEOPLASMS. 233 

It is our purpose to treat the subject of New Growths in a 
separate chapter, and to include all neoplasms, both benign and 
malignant, occurring within that portion of the respiratory tract 
that is within the scope of this work. The classification given 
above is constructed upon a histologic basis, and is practically that 
given by the late Professor Gross, as well as that used by J. Bland 
Sutton in his work on Tumors. Much has been written in regard 
to the transition of benign growths into malignant in the nares, 
nasopharynx, and larynx. The simple typical papilloma is fre- 
quently found. This in itself is a non-malignant tumor. It is a 
well-established clinical fact that slow chronic irritation of such a 
tumor tends to produce carcinoma, and that trauma may produce 
sarcoma. There is no histologic reason why this cannot occur. 
In the locations mentioned, nares or larynx, the irritation is likely 
to be chronic. By this attrition from the epithelial elements pres- 
ent, carcinoma may develop, or from trauma, the central portion, 
composed of connective-tissue elements, sarcoma may originate, 
there being no change of tissue-type, as the papilloma contains 
both epithelial and connective tissue. I grant that it is difficult 
to say whether the tumor was originally a simple papilloma, as a 
microscopic examination after malignancy develops would not 
settle the point. In the case reported by Ward of Pittsburg, the 
tumor when first seen was a simple papilloma, as was shown by 
the microscope, and yet there later developed at the site of the 
papilloma a carcinoma, which was also proven by microscopic 
examination. Frequently, in growths from the upper air-tract, a 
small portion is snipped off for examination. This is often a 
source of mistaken diagnosis. Even in malignant growths, the 
surface-epithelium may be intact, and the section show nothing 
malignant ; or marked inflammatory changes may be mistaken for 
malignant connective-tissue growth, as simple inflammatory cells 
are embryonic connective tissue. Or, again, the surface may be 
ulcerated, and the tissue removed include the ill-formed embryonic 
tissue beneath the ulcer, which cannot be distinguished from sar- 
coma, neither one having fully-formed vessel-walls. I have exam- 
ined a number of sections in which these errors could easily have 
occurred. 

Carcinoma of the upper air-passages is by no means a common 
occurrence. It may develop primarily, and spread by the lym- 
phatics to adjacent structures, or may originate in adjoining struct- 
ures and spread to the mucous-membrane surface ; besides, carci- 
noma usually attacks the more superficial structures. Sarcoma 
usually originates in the deeper structures and involves the mucous 
membrane secondarily. Both may tend to ulceration and second- 
ary changes. We may find in the structures of the respiratory 
tract any growth met with in the other structures of the body. 



234 NEOPLASMS OF THE RESPIRATORY TRACT. 

PAPILLOMA. 

Nares. — When a papilloma is located at the juncture of the 
skin and mucous membrane, it is usually of the hard variety, and 
resembles microscopically the skin-wart, consisting of an epithe- 
lial covering, with central vascular loop and lymphatic supply 
supported by connective-tissue elements. It is commonly single, 
although it may be found multiple ; usually lobulated, being sub- 
ject to constant irritation from its location, it is likely to be the 
site of malignant change — a fact equally true of such a growth 
elsewhere. Papilloma usually occurs in one orifice only. 

Treatment. — Unless exposed to irritation from location, the 
tumor being benign, surgical interference is not necessary ; but if 
subjected to irritation, it should be removed at once. If its pres- 
ence causes obstruction with subsequent catarrhal conditions, or it 
is associated with reflex irritation, it then becomes surgical and 
should be excised. This should be done by means of a sharp 
knife, lacerating the adjacent structure as little as possible. 

Nasal Cavity. — Papillomata within the nasal cavity occur, 
according to some writers, quite frequently. Hopmann maintains 
that they are often confused with polypi. In a polypus with con- 
siderable fibrous tissue (fibromyxoma), in which from any irrita- 
tion inflammatory processes take place, the organized inflammatory 
tissue from contraction would cause the tumor to simulate a papil- 
loma. Personally, I consider it a rare tumor of the nasal cavity. 

The common sites for the growth are the inferior turbinate, the 
lower and anterior portion of the septum, and the lining of the 
vestibule. It is most commonly of the hard variety, as is usually 
the case where there is squamous-celled epithelium, nor does it 
differ materially in microscopic appearance from the skin-wart, 
except that the epithelial covering is very thin. It is highly vas- 
cular and tends to ulceration ; it is usually single and small in size. 

Symptoms. — There is a sense of irritation within the nostrils ; 
often, profuse discharge due to the irritation ; at times there is 
slight pain. Although the tumor is usually small, it may attain 
a size sufficient to cause nasal obstruction. Slight bleeding may 
occur. Through reflex phenomena asthmatic cough may exist. 
If much bleeding and ulceration occur, a possibility of malignant 
change should be taken into consideration. 

Treatment. — Treatment should consist in complete removal by 
means of cutting-forceps or the knife. Acids should not be applied. 
In one case reported (Dunn) spontaneous separation occurred. 

Nasopharynx. — Papillomata of the nasopharynx are ex- 
tremely rare, only a few cases having been reported. These were 
of rather a mixed variety, resembling more closely villous papil- 
lomata, and were situated on the posterior inferior border of the 
inferior turbinate. 

Symptoms. — From the irritation produced by the presence of 
the tumor^ which is practically that of a foreign body, there exists 



PAPILLOMA. 



235 



a nasopharyngitis. The growth, depending on size and location, 
may obstruct nasal breathing, and also occlude the orifice of the 
Eustachian tube. Constant hacking, with a sense of the presence 
of some body in the nasopharynx, is present. In the cases reported, 
on pressure slight bleeding occurred. The growth was rapid and 
associated with nasal polypi. 

Treatment. — The tumor should be excised through the nostril 
or by the buccal route ; the latter is preferable in large growths. 

Pharynx. — Any portion of the pharynx may be the site of 
papillomata — the common location being the uvula, the free mar- 
gins of the pillars, or the tonsil. They may be multiple or single, 
and are usually of the soft variety ; they are often associated with, 
or rather follow, some inflammatory process. 

Symptoms. — The symptoms are obvious. 




Fig. 67.— Farnham's forceps, showing different forms of blades. 

Treatment. — Excise by means of cutting-forceps (Fig. 67), 
taking care to produce as little trauma as possible. 

I/arynx. — In the larynx the papillomata are the most com- 
mon of all benign growths. The condition has been the subject 
of considerable discussion. I see no reason, as stated on page 233, 
why such a growth may not exist, and also why, owing to irri- 
tation either from its location or from " tinkering " bv the larvn- 



236 NEOPLASMS OF THE RESPIRATORY TRACT. 

gologist's application of irritants (acids, etc.), this benign growth 
may not become the site of a malignant tumor (carcinoma), or in 
the young become the site of sarcoma. When located on the vocal 
cords, on removal and microscopic examination, the tumor is often 
found to have a predominance of connective (fibrous) tissue, raising 
the question as to its being a true papilloma, as well as lessening 
the tendency to the development of carcinoma (Fig. 88). The 
tumor being a fibrous papilloma this is probable, as there is no 
change of tissue-type, and the blending of the two types occurs 
in other varieties — e. g., fibro-adenoma. The different varieties 
of papilloma reported really depend upon the amount of fibrous 
tissue found and the extent of involvement of the subepithelial 
elements. The diffuse form — pachydermia diffusa — shows deep 
fibrous changes involving the subepithelial layer ; while the super- 
ficial variety — pachydermia verrucosa (Virchow) — affects not only 
the papillae, but there is also a proliferation of the surface-epithelium, 
the cells piling up into a wart-like growth. Macroscopically, these 
growths resemble the hard and soft papillomata. The tumor may 
occur at any age, and may be congenital, single or multiple, sessile 
or pedunculated, and present a variety of shape — mulberry, rasp- 
berry, cauliflower, or foliated. The common site is the anterior 
portion or angle of the vocal cords ; but it may occur on the ven- 
tricular bands and epiglottis. The tumor varies in size from that 
of a pin-head to that of a bulb sufficiently large almost to occlude 
the larynx. In adults, papillomata are of slow growth and usually 
occur high up in the larynx (supraglottic portion). In children, 
they are of rapid growth and may occur in any portion of the 
larynx. Syphilitic nodules occurring about the vocal cords and 
larynx resemble in many ways the papillomatous growth, and I 
have seen a number of these so-called papillomatous tumors dis- 
appear under a thorough course of iodids, proving, to be sure, that 
they were not papillomata, but specific granulomata. 

Symptoms. — The chief symptom is that of interference with 
the function of phonation, the extent of impairment depending 
upon location and size. A growth may occur in the ary epiglottic 
folds, epiglottic folds, or even the ventricular bands, without pro- 
ducing any marked alteration in the voice. At first, there is no 
interference with respiration even by reflex action. In children, 
spasmodic contraction of the muscles of the larynx may take 
place, owing to the presence of the tumor. As a rule, though, the 
interference is due to the tumor's size. Some dyspnea may exist 
when the growth is pedunculated and lies on the vocal cords. If 
it be above the cords, the dyspnea will be more marked on inspi- 
ration ; if below, on expiration, although spasm of the glottis may 
be produced in either case. The presence of the tumor usually 
excites a catarrhal inflammation of the larynx. Hemorrhage is a 
rare symptom, and occurs only in cases in which the growth is 



PAPILLOMA. 



237 



subjected to friction. When severe hemorrhage occurs, the tumor 
is most likely malignant. Pain, if present, is slight. 

Diagnosis. — This growth is not likely to be confused with 
any other than a beginning epithelioma. The papilloma occurs at 
any age, is a prominent grayish-white growth with irregular sur- 




Fig. 68.— Scheppegrell's self-adjusting electrocautery snare. Nasal, postnasal, and 
laryngeal electrodes. A rheostat in the handle regulates the current. 

face, yet intact epithelial covering, with slight, if any, tendency to 
bleed, and is located at the anterior portion of the vocal cords. 
An epithelioma occurs late in life — at least not in the young — is 




Fauvels laryngeal polypus-forceps. 



never tabulated, becomes diffuse, and involves adjacent structures. 
There is a tendency to ulceration and bleeding, and, while it may 



238 NEOPLASMS OF THE RESPIRATORY TRACT. 

have its site in any portion of the larynx, often begins in the pos- 
terior portion of the vocal cords. 

Prognosis. — Except in cases where the growth has attained 
considerable size, or from its location produced dangerous spasms 
or dyspnea, there is no immediate danger to life. Even when 
such conditions exist, the danger to life can be averted by the 
prompt performance of tracheotomy. I do not agree with many 
writers that such growths do not become the site of malignant 
change ; hence the prognosis would depend upon the prompt and 
complete removal. 

Treatment. — In the removal of the tumor, the operator should 
be guided in his method by the size and location of the growth. 
Whether it be by means of the knife or scissors, crushing or 
evulsion, the cautery or the snare (endolaryngeal) (Fig. 68), care 
should be taken to remove the entire tumor and to cause as little 
destruction of the normal structures as possible. The best in- 
strument for this purpose is the one devised by Dundas Grant 
and shown in Fig. 79. The use of chemicals should be avoided, 
as it is almost impossible to prevent their coming in contact 
with the normal structures ; besides, it is a slow process, and 
produces continued inflammatory reaction, which in papilloma, 
with its tendency to become the site of malignancy, should be 
carefully avoided. Rarely, if ever, is it necessary to open the 
larynx for the removal of this variety of benign growth. 

Injection of pure alcohol into these benign growths has been 
highly beneficial. However, should three or four injections at 
intervals of ten days fail to lessen the size of the tumor, its use 
should be discontinued. By placing the patient at rest and for- 
bidding the use of the voice for periods of from one to three weeks' 
duration, papilloma in children may entirely disappear without any 
surgical interference. 

The internal administration of calcined magnesia has given very 
beneficial results in some cases of papilloma of the larynx in chil- 
dren, but must be continued over a period of weeks or months. 

ADENOMA. 

Anterior Nares. — Adenoma of the anterior nares is of rare 
occurrence owing to the histology of the structure. Some cases 
have been reported of mixed tumors in which there was appar- 
ently gland-structure ; but simple adenoma of the anterior nares is 
practically a histological impossibility. It may occur, however, at 
the nasal orifice. 

Nasopharynx. — The only gland-structure in the nasopharynx 
is that known as the pharyngeal tonsil, which is a conglomerate 
gland and does not belong strictly to the adenomata, so that pure 
adenoma of the nasopharynx does not commonly occur, although 
its occurrence has been noted. 



ADENOMA. 



239 



Fauces. — Owing to the histological structure of the soft 
palate, especially of the posterolateral surface, and owing to the 
great number of muciparous glands in this lax structure, and also 
to the fact that it is the common site of an inflammatory process, 
cystic adenoma may occur in this location. The simple adenoma, 
however, is rare, the growth usually being in reality an adeno- 
fibroma (Fig. 70). 

Its etiology is identical with that of any benign growth which 
is adult in type, and falls short only in function. It is most com- 
mon in adult life, occurring as late as the fiftieth to sixtieth year, 
Statistics show that it is more common in females than in males. 




Fig. 70.— Adenofibroma. a. Transverse and partially oblique sections of acini ; b, fibrous 

connective tissue. 

Symptoms. — Like all benign growths its development is slow, 
and the symptoms produced are simply due to obstruction — in 
fact, are identical with the symptoms of adenoid vegetations in 
early life. The nasopharyngeal symptoms due to adenomata 
occurring in this location in adult life would not consist in the 
same amount of nasal irritation and interference with nasal respira- 
tion and development as would be shown if occurring in childhood. 
There are a sense of fulness in the throat, some interference with 
deglutition — or rather a continual desire to swallow an imaginary 
body — occasionally pain, but only when the terminal nerve-fila- 
ments are involved ; and, as a benign tumor does not contract, it 
would necessitate an accompanying inflammatory process. From 
pressure there may be erosion and hemorrhage, which is only 
slight, as the tumor is not vascular. 

Pathology. — An adenoma is a simple hyperplasia of gland- 
structure, having its type in the acinous or tubular gland-struct- 
ure. It may become cystic from obstruction of the duct and 
undergo mucoid degeneration. It is usually sessile in shape. 



240 NEOPLASMS OF THE RESPIRATORY TRACT. 

Diagnosis. — 

Fibroma. Adenoma. 

Develops rapidly. Develops slowly. 

More painful. Less painful. 

Interference to greater extent with No great amount of interference with 

function. function. 

Kare. Common. 

Earlier decades. Twenty -five to sixty years. 

Treatment. — If the tumor is of sufficient size to interfere with 
the normal function of the part, surgical interference should be 
instituted. As the lesion is not a malignant one, and the removal 
of the entire growth might necessitate interference with the ana- 
tomical structure of the soft palate, only a portion of the tumor 
should be removed. If the growth is single and encapsulated, it 
should be carefully dissected out and removed en masse. If mul- 
tiple, the same rule should be applied to each individual tumor. 

larynx. — From the histological structure of the larynx, there 
is not much likelihood of a pure simple adenoma developing there. 
Consideration of adenoma of the larynx as a purely benign growth 
necessarily involves the question of malignancy, because it is a 
well-known fact that tumors of the adult epithelial type — namely, 
adenoma and papilloma — when located where they will be sub- 
jected to constant irritation, may become the sites of malignant 
growth. This question is one which has been discussed by the 
pathologist, the laryngologist, and the surgeon. Regardless of 
theories and dogmatic statements, either by the clinician, the 
laryngologist, or the pathologist, the fact remains that quiescent 
tumors of the larynx may suddenly develop into rapid and unex- 
pected malignancy. Whether it was merely a latent carcinoma, 
or whether it was a benign tumor, which from irritation became 
the site of malignant growth, it matters little, but the clinical fact 
remains that, regardless of the name applied to the neoplasm, 
when it occurs Avithin the vestibule of the larynx, its removal as 
early as possible should be insisted upon. 



ANGIOMA. 

Nasal Passage. — Angioma of the nasal passage is of rare 
occurrence, but, when found, is seen more frequently on the septum 
than on the turbinal wall. Like the other benign tumors, there is 
no assignable etiological factor for its existence ; but like all vascu- 
lar tumors, it seems to consist rather of a distention of the already 
existing vessels than a new growth of vessels. This distention, 
however, differs from that due to congestion or that caused by the 
circulation itself, for it is brought about by an alteration in the 
vessel-wall which may be the result of some deficient nutritive proc- 
ess. Whether or not it be of import from an etiological standpoint, 
it is clinically true that these vascular tumors are more likely to 




Fig. 71.— Angioma of septum. 



ANGIOMA. 241 

occur in individuals of a lymphatic temperament. It is impossible 
to say whether this is due to any peculiar formation of the vessel- 
wall in these individuals, or whether it is the effect of the low-grade 
nutrition secondarily affecting the wall ; yet the clinical fact remains. 

Symptoms. — Because the tumor acts as a foreign body, the 
main symptom is that of obstruction, to a degree depending 
entirely on the location of the growth and its size. There is 
little, if any, pain. If the obstruction is marked, there will be 
considerable mucopurulent discharge. Bleeding may occur, and, 
while in most cases it is only slight, yet in angioma, especially of 
the septum (Fig. 71), hemorrhage may be considerable. This is 
especially true if it is located well down toward the nasal orifice. 
The continued slight loss of blood may eventually produce altera- 
tion in the patient's general health. Angiomata rarely reach such 
dimensions as to cause any nasal deformity. The common varie- 
ties of these growths occurring in the nasal passages are the sim- 
ple and cavernous. Simple angioma is usually small and rather 
smooth on the surface, and may or may not be congenital. On 
microscopic examination the sections will show the vessels thin- 
walled, held together by fibrous or cellulo-adipose tissue. As a 
rule, there is a communicating vessel, larger than those found in 
the tumor-mass, which connects it with an adjacent artery or vein. 
In the cavernous variety the vessels are much larger, and the 
tumor is more irregular on the surface. On section the vessels 
show as irregular sinuses separated by thin fibrous walls. Either 
variety is more frequently found in early life ; but rarely, if ever, 
in old age. When involving the nasal mucosa, if its origin be in 
the submucosa, it may be apparently encapsulated. This capsule 
is formed by the tissue which is crowded up ahead of the tumor 
by the distention. In such cases the growth will be covered with 
a thin layer of epithelium, and there may be infiltration of small 
round cells, and leukocytes and proliferation of the fixed connec- 
tive-tissue cells. Angioma, hematoma, and telangiectasis may 
occur on the lips, cheek, gums, and tongue. 

Diagnosis. — The tumor can be reduced largely by pressure. 
As a rule, it pulsates, especially when in communication with an 
artery. Pulsation is slight if the communication be with a vein. 
Angiomata bleed easily, and great care should be exercised in 
examination to prevent hemorrhage. The color necessarily varies, 
depending on the size of the tumor, its association with vein or 
artery, or with both. If the growth is connected with an artery 
alone, it is usually light red_, and distinctly pulsates. If the com- 
munication be with a vein, the tumor will be darker in color, blu- 
ish-red, and the pulsation will be slight or absent. If, however, 
the communication be with both vein and artery — which I believe 
to be the case in most growths of this character — the tumor will 
be dark red. The color of the surface will also be controlled 
largely by whether the tumor is superficial or more deeply seated. 

16 



242 NEOPLASMS OF THE RESPIRATORY TRACT. 

Prognosis. — The prognosis necessarily depends on the surgical 
interference, which, if conducted properly, should entirely relieve 
the patient. Angiomata do not tend to recur. 

Treatment. — The best plan for removal is to exert pressure 
slowly on the pedicle of the tumor. This can best be done by the 
use of the cold- wire snare, employing heavy wire and gradually 
constricting until the pedicle is entirely cut through. This slow 
process is by far the best method, as rapid removal is always 
attended by serious hemorrhage. Angioma of the septum occa- 
sionally appears as a sessile growth. In such formation it will be 
difficult to retain the snare-wire at the base of the tumor. This 
difficulty can be overcome by placing the loop in position and, 
before tightening the snare, transfixing the tumor with a needle, 
so as to hold the wire in position ; then use the slow method of 
strangulation. The growth can be removed by silk ligature, passing 
a number of sutures through the tumor and ligating. The remain- 
ing stump should be cauterized carefully with 20 per cent, chromic 




Fig. 72 — Delavan's electrolysis needles, unipolar and bipolar. 

trichloracetic acid, 1 : 2000, or the galvanocautery. Bipolar elec- 
trolysis (Fig. 72) may prove effective in selected cases. 

Fauces. — Angioma of the fauces rarely appears in the simple 
form, but is usually a mixed variety of tumor. The etiology and 
pathology of angioma in this locality do not differ from those given 
for the nares. The common site is the lateral walls of the pharynx. 
Owing to the vascularity of the parts, the vessels of the tumor 
occurring in this location are likely to be larger, and the tendency 
to hemorrhage more marked. The only symptoms of importance 
are the feeling of obstruction in the throat — as of an imaginary 
foreign body — pain on swallowing, and a tendency to hemorrhage. 

In the removal of an angioma in this location, the galvano- 
cautery should be used instead of the cold-wire snare, and while 
by its use the hemorrhage can better be controlled, yet it must be 
borne in mind that to the wound there is added trauma — a burn. 

Great care should be exercised in the removal of an angioma, 
owing to the tendency to hemorrhage. 

Pharynx and Uvula. — The bundle of veins at the back of 
the pharynx, known as " Cru veil trier's submucous venous plexus," 
has been reported as becoming engorged and varicosed to the 



CHONDROMA. 243 

extent of causing a disagreeable fulness in the throat and an irri- 
tating cough. 

It has been our good fortune while preparing this book to see — 
but once, however, and that but for a short time — an exceedingly 
interesting case of angioma of the uvula occurring in the service of 
Dr. Alexander MacCoy, at the Pennsylvania Hospital. The patient, 
a colored woman, complained of a lump in her throat. On inspec- 
tion the uvula was found to have been enormously enlarged into 
a tumor, covered with distended and black veins, extending down 
into the pharynx. This could be pulled up out of the pharynx 
with a probe and laid on the tongue. 

Tonsil. — Angioma varicosa has been reported as occurring in 
a limited number of cases on the tonsil. The tumor is composed 
largely of capillary blood-vessels with a thin, but firm, connective- 
tissue stroma. Slow and careful removal with the cold-wire snare 
should be the treatment. 

I/arynx. — Angioma in the larynx is exceedingly rare, but 
cases have been reported involving the ventricular bands, the 
epiglottis, the hyoid fossa, and the lingual sinus. When occur- 
ring in the locations mentioned above, the tumor is usually small, 
of a bright-red color, racemose in appearance, and usually uni- 
lateral. 

Treatment. — The only treatment to be instituted is complete 
removal. This will have to be done, if the tumor is small, by the 



Fig. 73.— Gibb's laryngeal ecraseur. 

use of the cold-wire snare (Fig. 73). Owing to the location, the 
slow process will be very difficult. If the tumor is of large size 
and very vascular, it may necessitate a thyrotomy with, possibly, 
a preliminary tracheotomy. 

CHONDROMA (ENCHONDROMA). 

Nasal Passage. — While some authorities consider chon- 
droma, enchondroma, and ecchondroses as synonyms, from a patho- 
logical standpoint the last-named should be classed under inflam- 
matory thickenings occurring in the septum. As a chondroma is 
purely a benign tumor of the adult connective-tissue type, it should 
not be confused with inflammatory processes of any character or in 



244 NEOPLASMS OF THE RESPIRATORY TRACT 

any situation. Pure chondroma of the nasal cavities is rare, but, 
when found, is usually located at the junction of the cartilaginous 
septum with one of the alar cartilages — L e., at the posterior inferior 
angle of the cartilaginous septum. The tumor is usually small, 
round, and nodular, is clinically somewhat like fibroma, and micro- 
scopically contains cartilage-cells. It usually occurs early in life, 
and, like all the benign tumors, has no assignable cause for its 
existence. It is usually found in one nostril only. 

Microscopic examination will show hyaline cartilage-cells, 
poorly formed in places, with areas of cystic degeneration. At 
various points there may be slight tendency to ossification, which 
is, in reality, only a deposition of lime salts instead of an attempt 
at organization of osteoblasts. The base of the tumor will show 
some fibrous tissue containing capillary-loops. 

Symptoms. — The amount of nasal obstruction will depend 
entirely on the size of the tumor. It is usually sufficiently large, 
however, to cause partial stenosis, which in turn produces an 
accumulation of secretion that may become mucopurulent and 
offensive. The tumor may reach sufficient size to cause external 
nasal deformity. As a rule, there is no pain except from pressure 
due to size or location. Owing to the non- vascularity of the 
tumor, there is no tendency to hemorrhage, except where the 
mucous membrane covering the bony growth has become inflamed 
and ulceration follows. Chondroma is of exceedingly slow growth. 

Diagnosis. — The tumor is very dense and immobile ; its color 
is yellowish-white or pink ; it may be irregular and nodulated — 
hard, yet slightly springy to the touch. Perforation with a sharp- 
pointed needle will differentiate the growth from osteoma. Fibroma 
is usually pedunculated, yields more to pressure, and usually does 
not spring from the septum. 

Prognosis. — The prognosis is good, as regards after-effects, if 
the tumor has been removed before any nasal deformity has taken 
place. 

Treatment. — Complete removal can be accomplished by the 
cold-wire snare, or the author's saw (Fig. 53), or the saw-file 
shown in Fig. 74, or there is no objection to the use of the knife, 
as there is no tendency to great hemorrhage. 




W^5%\% J* 



B 55°S 40°. 

Fig. 74.— Fetterolf s saw-file : A, side view ; B, face view ; C, elevation or cross-section. 

Nasopharynx. — Only two cases have been reported of chon- 
droma occurring in the nasopharynx, and both were in young 
adults. 



EXOSTOSIS. 



245 



I/arynx. — Chondromata of the larynx usually involve the 
cricoid cartilage, but the thyroid, epiglottic, and arytenoid carti- 
lages are more rarely the site of the growth. Usually they 
extend inward, and are sessile and immovable. They may attain 
considerable size, causing dyspnceic symptoms. The irregular sur- 
face of the tumor is, as a rule, covered with a slightly hyper- 
emic membrane, and the bleeding which occurs is from this 
structure. The body of the tumor is composed of hyaline carti- 
lage, except when it arises from the epiglottic cartilage, when it 
contains more fibrous structure. Some calcification may take 
place. This, however, occurs in localized areas. 

Diagnosis. — Chondroma is hard, dense, somewhat lobulated, 
and exceedingly slow in development. The most common site is 
the cricoid cartilage. The following table gives the points of dif- 
ference in the conditions with which chondroma may be confused : 



Perichondritis. 


Carcinoma. 


Chondroma. 


Usually some assign- 


None. 


None. 


able cause. 






Any age. 


Late in life. 


L'suallv earlv in life. 


Sudden onset. 


Slow. 


Slow. 


Acute local inflamma- 


Inflammatory symp- 


No inflammatory con- 


tion. 


toms late. 


ditions, except produced 
by obstruction. 


Early tendency to 


Late, if any. 


Late, if any. 


edema. 






May involve any of the 


Rarelv below the glot- 


Common site cricoid 


cartilages. 


tis. 


cartilage. 


Localized. 


Tends to spread with 


Localized ; no tendency 




glandular involvement. 


to spread. 



The prognosis is good if the tumor is removed early. 

Treatment. — Chondromata can, if small, be removed by 
cauterization or the biting-forceps. If of greater bulk, a thyrot- 
omy may be necessary to remove the growth successfully. 



EXOSTOSIS. 

The term exostosis, according to Ziegler, may be applied to 
either bony or cartilaginous growths. One variety, which springs 
from cartilage or bone, and which may be partly cartilaginous or 
entirely bony in structure, is known as a connective-tissue exos- 
tosis. The other variety, which springs from cartilage alone, is 
known as a cartilaginous exostosis or ecchondrosis. These growths 
occur in the nostril, either from the septum or turbinated bones, 
and are commonly referred to as spurs, crests, ridges, excrescences, 
or redundancies. 

The bony or connective-tissue exostosis may be situated ante- 
riorly on the cartilage of the septum, or posteriorly on the 
vomer ; or they may spring from the floor of the nostril, or from 
any of the turbinates, but more commonly the middle. "When 



246 NEOPLASMS OF THE RESPIRATORY TRACT. 

growing from the turbinate bones, the growth is more in the shape 
of a spur, and may extend entirely across the nasal orifice. Its 
only pathological significance is the mechanical obstruction to the 
nasal respiration. An exostosis may spring directly from the bone 
or from the periosteum, and is always covered with a layer of 
mucous membrane. The growth in the turbinal area is slightly 
sessile, but not so markedly so as those occurring on the vomer or 
cartilaginous septum. These growths, either cartilaginous or 
bony, may be congenital. They may be the result of malforma- 
tions or traumatic deformities. Whether inflammatory processes 
have anything to do with their origin is questionable. I am 
inclined to think that the existing catarrhal condition, which is 
always present, is rather the result of the growth, than that the 
growth is the result of an inflammatory process. The cartilag- 
inous spur on the septum usually appears as a short ridge close 
to the floor of the nose, at the junction of the cartilage with 
the bone ; at least it is most frequently situated in the lower 
third of the septum. At first it may be entirely cartilaginous, 
but later may become decidedly bony, and in some cases be as 
firm and dense as the eburnated variety of bone, rendering it 
almost impossible to use the ordinary nasal saw in its removal. 
In some cases I question whether this is actually bony formation, 
or whether it is not more of a calcareous infiltration. If it 
involves the posterior part of the cartilaginous septum or extends 
over to the vomer or bony septum, the growth resembles a ridge 
or fold, the anterior portion being partially cartilaginous, while 
the posterior part is more bony, but in either case is covered by 
mucous membrane. Quite frequently this ridge or projection has 
on the opposite side of the septum a corresponding depression. 
This fact must not be overlooked before the removal of the spur, 
else the septum may be permanently weakened or even perforated. 
Treatment. — First, unless the ridge or spur is so located as 
to form mechanical obstruction to nasal respiration, or by its pres- 
ence cause accumulation of secretion, thereby being a source of 
irritation, its removal is not necessary, as the resulting scar will be 
of more injury to the individual than the spur or ridge. If there 
be associated any peculiar reflex phenomena without any assign- 
able cause, the physician is justified in the removal of the ridge as 
a tentative curative measure. When the spur is to be removed, 
the mucous membrane should be carefully dissected up from the 
lower margin of the growth after the tissue has been benumbed by 
the application of a local anesthetic, preferably a 6 per cent, solu- 
tion of cocain. The projecting spur may then be removed by means 
of saw, biting-forceps, or the alligator-jaw forceps shown in Figs. 
52 and 67). Personally, I prefer to use the saw shown in Fig. 53, 
which is easily handled ; the cutting surface can easily be controlled, 
and with this instrument the growth can be removed without 
injury to adjacent structure. Besides being able to control the 



FIBROMA. 217 

cutting surface of this saw, it has a double cutting edge, which 
does not tend to jump — one of the objections to the long nasal saw. 
The gouge can be used advantageously in some cases. After the 
removal of the cartilaginous or bony portion, the flap, which has 
been dissected up, should drop over the denuded surface. Unless 
there is severe hemorrhage, the nostril should not be packed, but 
should be left freely open, and should be douched from four to six 
times in twenty-four hours with an antiseptic solution. After the 
first twenty-four hours the cleansing solution should not be used 
more than twice daily, as the irritation will retard healing. For 
this purpose there should be used hydrogen peroxid 1 part, and 
cinnamon water 2 parts. If the flap should become infected and 
slough, and an ulcer form, it should be touched with a 3 per cent, 
solution of formalin ; or, if this prove very painful, a 1 per cent, 
formaldehyd solution in 4 per cent, cocain should be used. The 
surface should then be dusted over with 5 per cent, pyoktanin in 
stearate of zinc. The majority of cases, owing to the vascularity 
of the part and the recuperative powers of the mucous membrane, 
heal promptly, usually in a few days, rarely longer than two 
weeks. Occasionally, owing to local infection or to blood dys- 
crasia or latent constitutional condition, it may be almost impossi- 
ble to promote healing. While this does not often occur, it is 
well, as in all operations, to acquaint your patient with the fact 
before operating. 

FIBROMA. 

Nasal Passage. — Fibroma involving the nasal cavity may 
exist as a simple tumor, but, as a rule, it is either in a mixed form 
or has undergone some degenerative process. As the growth is a 
connective-tissue tumor, it must necessarily spring from the adult 
connective-tissue element — that is, the submucosa. This tumor 
demands a high grade of nutrition, and usually springs from a 
highly vascular area. Its morbid histology is very much the 
same as simple fibroma in other locations (Fig. 75). The micro- 
scopic appearance, especially if the tumor be the site of some 
inflammatory process, may be confused with small spindle-cell 
sarcoma. Fibromata usually occur early in life — from the fifteenth 
to the thirtieth year — and are most common in males. When 
degenerative processes have taken place in the tumor, and if the 
tumor is subjected to much irritation, it may be the site of malig- 
nant growth. Fibromata rarely ever spring from the septum. 
The common site is the posterior and inferior margin of the 
middle turbinate, which would necessitate the involvement of the 
postnasal space. When located in the anterior nares, they usually 
spring from the lower margin of the middle turbinate, or they 
may be found growing from the anterior portion of the superior 



248 NEOPLASMS OF THE RESPIRATORY TRACT. 

turbinate. I saw one case in which the fibroma, which was 
pedunculated, had its origin in the floor of the nose. The shape 
of the tumor is controlled somewhat by its location. When occur- 
ring in the nasopharynx, it is apt to be pear-shaped, although 
pedunculated. If found in the anterior nares, they are usually 
not so large and markedly elongated. Early in the development 
of fibroma there is practically no pain, and it is only when the 
tumor reaches a large size that there is associated pain, which is 



I :: 







, j ' ' 


1 V 


\l 






V 




v 


U I , ' ' ' 

Fig. 75.— Simple fibroma. 


w 



caused by pressure on adjacent structures rather than occurring in 
the tumor proper. There is often considerable epistaxis, which 
may be not only from the tumor, but also from the adjacent 
mucous membrane, which has become ulcerated by pressure. 
The nasal obstruction will necessarily depend on the size of the 
tumor, which is frequently of sufficient size to obstruct the nasal 
cavity entirely, and even produce external nasal deformity. There 
is often associated partial loss of smell, which may be due to direct 
pressure of the tumor, or may be brought about by inflammatory 
processes due to its presence. There will be lack of nasal reso- 
nance, giving a peculiar nasal twang to the voice. The pathology 
of nasal fibroma is practically the same as for the growth else- 
where, except that it is often highly vascular and the blood-vessel 
walls are markedly thinned. The fibrous network, instead of 
consisting of bundles of fibers, will show more spindle- or stellate 
cells, rendering it difficult to differentiate from the small spindle- 
cell sarcoma. Fibroma maybe associated with a myxoma, or it 
may be a simple fibroma which has undergone myxomatous 
degeneration. 

Diagnosis. — As a rule, the application of cocain to any of the 
benign or malignant growths is an uncertain aid to diagnosis, as 
hyperplasia is only slightly affected by this drug. The sense of 



FIBROMA. 249 

touch is one of the best diagnostic features. There is a certain 
amount of springiness and firmness in fibroma, which can be 
detected by the probe or finger. If the tumor is rather large 
and extends into the nasopharynx or projects from the nasal orifice, 
the dependent portion will be rough and feel very much as if the 
finger were passed over a hard papilloma, or it may resemble dis- 
tinct papillae, or possibly may be more like shrunken leather. The 
tumor usually appears singly, but may be multiple. It may be 
lobulated and nodular. The so-called frog-face, which is possibly 
more marked in fibroma than in any other form of nasal obstruc- 
tion, is not pathognomonic, because any obstruction in the nose 
which causes pressure will obstruct venous return. This in turn 
will give a swollen appearance to the external portion of the nose 
and cheeks, and obliterate the labionasal fold, which individualizes 
facial expression. 

Prognosis. — The prognosis necessarily depends on the prompt 
removal of the growth. If this is done before any serious patho- 
logical alteration in structure has taken place, the outlook is good. 

Treatment. — Prompt removal by means of the cold- wire snare 
is possibly the best plan of treatment, although, if the tumor is 
pedunculated, the pedicle may be firmly grasped by the hemostatic 
forceps and thoroughly compressed ; the tumor may then be 
removed by the alligator-jaw forceps (Fig. 52) or the ordinary 




Fig. 76.— Potter's serrated scissors. 

saw-scissors (Fig. 76). The compression, which practically 
amounts to torsion, would prevent any marked hemorrhage. 
Should hemorrhage occur, it can be controlled by douching or 
spraying the nostril with cold water or by the ice pack. Should 
the procedure fail to control the flow of blood, the nostril at the 
point of oozing or bleeding may be packed with antiseptic gauze 
saturated with hydrogen peroxid, which serves a double purpose, 
acting as an antiseptic as well as coagulating the albumin in the 
the blood, thereby increasing the tendency to clot-formation. 

Nasopharynx. — Simple fibroma may spring from, and be 
located purely in, the nasopharyngeal space. Its common site of 
origin is from the basilar process of the occipital bone, a location 
from which it slowly, but surely, spreads. There seems to be no 



250 NEOPLASMS OF THE RESPIRATORY TRACT. 

law controlling the rate or direction of its growth. It may extend 
upward, producing displacement of bony structure to such an 
extent as to demand prompt and thorough surgical interference. 
On extending downward it may fill the nasopharyngeal space, and 
even involve the pharynx. 

The symptoms will be controlled by the extent of the growth 
and the line of involvement. If the tendency is downward, there 
will be early impairment of the voice-resonance, the sensation as 
of the presence of a body in the pharynx — causing continuous 
swallowing — sensitiveness of the surrounding parts, and slight 
tendency to hemorrhage, and the individual will have a gaping 
appearance, owing to the necessitated mouth-breathing. If the 
growth extend upward, the symptoms will be the same as de- 
scribed for growths occurring in the posterior part of the anterior 
nares, although there may be more persistent headache and a 
greater feeling of pressure over the bridge of the nose. When 
the tumor extends downward, there will be interference with the 
normal faucial movements ; owing to the obstruction and some 
partial paralysis from pressure, there will be loss of motion of the 
soft palate and uvula. The morbid histology of the tumor in this 
location differs from that found in the nasal cavity only in the 
fact that there are more bundles of fibers and fewer individual 
stellate cells. This is possibly due to the fact that in the naso- 
pharynx and fauces there is more connective tissue present. 

The diagnosis is practically that given for nasal fibroma. 

Prognosis. — Fibroma of the nasopharynx is of more serious 
import than when situated in the anterior nasal chambers, and the 
prognosis depends on the early and thorough removal of the 
growth. In early life, owing to the changes in the pedicle, the 
tumor may have undergone retrograde change, which might be 
followed by spontaneous cure. 

Treatment. — Beneficial results have been claimed by many 
from the injection of certain drugs, such as saturated solution of 
chlorid of zinc or a few drops of dilute acetic or hydrochloric acid. 
In my own hands I have not obtained good results from this 
method. Electrolysis has produced favorable results, using a 
strong current under general anesthesia. I think a more prom- 
ising mode of treatment is the introduction of drugs by means 
of the electric current, known as cataphoresis, although in my 
own experience I have not had sufficient permanent clinical 
results to warrant absolute statements. The safest plan for com- 
plete and satisfactory cure is to remove the entire mass by means 
of the cold-wire snare. The instrument shown in Fig. 77, devised 
by Stucky, is a most admirable one when the tumor is sessile or 
very fibrous. 

Tonsil. — A few cases have been reported of fibroma of the 
faucial tonsil. As fibroma develops from connective tissue, it must 



FIBROMA. 



251 



have its origin in the trabecule of the tonsil. Tumors in this loca- 
tion are usually of the fibroplastic variety. They are of very slow 
growth, and the symptoms produced by them are largely mechan- 
ical, being practically the same as caused by an enlarged or hyper- 
trophied tonsil. If the tumor should be pedunculated or attain con- 
siderable size, it may interfere with respiration, owing to its press- 
ure on the larynx, or owing to interference with the movements of 
the epiglottis, when dyspnea of an alarming nature might be 
produced. The question of diagnosis may be determined before 
operation by the removal of a small portion of the tumor, as the 
extent of the surgical interference will be determined by its 
benign or malignant character. The growth can be removed 
by means of the cold-wire ecraseur, either en masse or piece- 
meal. If the tumor is not highly vascular, it may be removed 
by the ordinary tonsillotome. Should tonsillar adhesions exist, 
they should be broken up before the attempt at removal. 




Fig. 



-Stucky's biting forceps. 



I^atynx. — In any case in which there is a new growth involv- 
ing the laryngeal structure, especially about the vocal cords, 
either intrinsic or extrinsic, in the question of diagnosis, specific 
lesions should always be eliminated by the therapeutic test before 
a positive diagnosis is made. In hereditary or acquired syph- 
ilis there is frequently fibroid thickening about the tissues of the 
pharynx and larynx. Any trauma of the neck involving these 
structures is liable to be the exciting factor in a new growth, and 
the enlargement following any such injury where there is either 
hereditary or acquired latent specific lesion must be carefully dif- 
ferentiated from malignant and benign growths. The one is a 
tissue change and the other is a new growth. 

Frequently tumors of the trachea produce laryngeal symptoms, 
especially thickening and edematous condition about the cords. 

Whether irritation has anything to do with benign growths 
as an etiological factor there is much diversity of opinion. Per- 
sonally I believe it may be an exciting factor, yet I do not be- 
lieve that the tumor of itself is of inflammatory origin. The 
high vascularity and the constant exposure of this portion of the 



252 NEOPLASMS OF THE RESPIRATORY TRACT. 

respiratory tract — the larynx — seem to make it a favorite site for 
benign growths. The constant irritation, I believe, has more to 
do with malignant neoplasms than with benign. 

Fibroma of the larynx usually originates in the vocal cord, no 
special selection as to right or left being noticed. As a rule, the 
tumor is not of large size, not for any histologic or pathologic 
reason, but from the fact that its location directs attention to its 
presence very early in its growth, and its prompt removal thus 
early prevents further increase in size. Although general consti- 
tutional conditions or local inflammatory changes may tend to the 
development of fibroma, the fact remains that they are often dis- 
covered in a larynx which has been previously perfectly normal 
and healthy. Besides, fibroma in other locations is by no means 
necessarily associated with inflammatory process, and there is no 
reason why it should not be controlled by the same laws when 
occurring in the larynx. 

Symptoms. — One of the first symptoms manifested, especially 
if occurring above the glottis, is the interference with phonation. 
This may be inspiratory or expiratory, but it gradually becomes 
permanent. The tumor acts as a foreign body, and there is fre- 
quently associated spasmodic contraction of the laryngeal muscles. 
There is usually considerable cough brought about by the constant 
irritation of the movable foreign body. There may be slight pain, 
but, as a rule, this symptom is absent. Should ulceration occur, 
there will be hemorrhage, but, as the fibroma is one of the well- 





Fig. 78.— Schroetter's improved laryngeal tube-forceps. 

nourished tumors, ulceration is not likely to take place unless pro- 
duced by friction. Next to the papilloma, the fibroma is the tumor 
most frequently found in the larynx. It is generally seen in the 
young or in early adult life, and is very rarely seen in the adult 
or aged. The mucous membrane covering the tumor — and in this 
location it usually has a mucous-membrane covering — is highly 
vascular. Fortunately, the tumor is, as a rule, single, although it 
may be lobulated. Just as unfortunately, it is usually sessile, the 
pedunculated variety being easily removed. 

Diagnosis. — By its smooth and vascular surface it may be 
differentiated from papilloma occurring in this location. At the 



LIPOMA. 



253 



same time, if the papilloma be smooth or of the fibrous variety, 
only the microscope can substantiate the diagnosis. 





Fig. 79.— Grant's laryngeal scissors. 

Prognosis. — The prognosis is good as to the complete removal 
of the tumor, yet its size, its location, and the manner of removal 
will determine whether there will be any alteration in the voice. 

Treatment. — On account of the great interference with respira- 
tion, endolaryngeal operation is usually impossible. Tracheotomy 
should be first performed under eucain anesthesia. The trachea 
should then be opened above the tube, and gauze packed about 
the tube to prevent the entrance of blood. The tumor can then 
be removed by means of the biting-forceps (Fig. 78) and the 
curet, or by the Dundas Grant instrument shown in Fig. 79. 
Such a case is reported by John W. Farlow of Boston. 



LIPOMA. 

Nares. — Lipomata involving the anterior nasal cavity consti- 
tute an exceedingly rare condition, while their occurrence on the 
external surface of the nose is by no means uncommon. They are 
usually situated on the alar portion, and are pendulous masses, 
usually containing considerable fibrous tissue. They really con- 
stitute localized elephantiasis. 

Nasopharynx. — One case has been reported by Bach in 
which lipoma occurred in the right fossa of Rosenmuller. There 
is no histologic reason why lipoma should not occur in any struct- 
ure containing connective-tissue elements. It must be remembered, 
however, that fatty degeneration may occur in any benign growth, 
which might be the source of error in diagnosticating a given 
tumor, not strictly a lipoma, but some other benign growth, which 
has undergone fatty degeneration. 

Tonsil. — Lipoma of the faucial tonsil is of rare occurrence. 
But few cases have been reported. 

Pharynx. — Lipoma of the pharynx is of rare occurrence, 
only one case having been reported, in which the tumor had its 
origin in the left side of the epiglottis and lateral pharyngeal wall. 



254 NEOPLASMS OF THE RESPIRATORY TRACT. 

The symptoms produced were mechanical, and were those of a 
movable foreign body in the pharynx. In the case reported the 
patient was over eighty years of age. 

I<arynx. — Only 10 cases of lipoma of the larynx have been 
reported. Of these 5 were removed during life. Two of the cases 




Mathieu's throat-forceps. 



were reported by McBride, 1 by Hohlbreck, 1 by Schroetter, and 
1 by Bruns, showing the tumor to be exceedingly rare. In 
the cases reported, the tumor was situated in the aryepiglottic 
folds the sinus pyriformis, the ventricle of the larynx, or else- 
where within the laryngeal cavity. The tumor in this locality 
does not differ in its histology from the ordinary lipoma. It may 
be single or multiple, and is usually not of large size. It may be 
sessile or pedunculated, and is usually covered with a mucous 
membrane consisting of thickened epithelial layers. There is a 
tendency for lipoma to recur, which would suggest a possible 
malignant tendency of the growth. The tumor, which is soft, 
may be removed by means of the biting-forceps (Fig. 80) or curet. 
There is a very slight tendency to hemorrhage. 

OSTEOMA. 

Nares. — Osteomata of the nasal passages may be growths pri- 
marily from the bony or cartilaginous walls of the nose, or may 
have their origin in some of the accessory sinuses, and project 
thence into the nasal cavity. The tumor usually originates high 
up in the nasal passage ; its shape is largely determined by press- 
ure from surrounding structures, which is usually considerable — 
indeed, often of such an extent as to produce marked deformity. 
Like osteomata in any location, they are of two varieties, eburnated 
and cancellous. The tumor may have its origin from the juncture 
of bones or the union of bone with cartilage. The proliferation of 
the osteoblast usually begins in the periosteum. The actual cause 
of the bony growth is not known. 

Pathology. — While the tumor is divided into the eburnated 
and cancellous, both varieties of bone are usually present, one or 
the other predominating. As an osteoma may spring from either 
cartilage or bone, it is possible that it may have its origin in 
latent cartilage- or bone-cells. Some are inclined to the theory 



OSTEOMA. . 255 

that minute centers of calcification have to do with the origin of 
the tumor, but this is not in accord with modern pathology, as 
calcification is a process of infiltration of lime salts and of their 
deposit within tissue. By their presence and from the cause which 
would lead to their presence, nutrition would naturally be inter- 
fered with. This would not tend toward new growth, but rather 
toward degenerative processes. The accessory cavity from which 
osteomata usually spring is the ethmoid sinus. Osteoma, like all 
the benign connective-tissue growths, while following its type as to 
structure, falls short in its physiology. In this tumor, the Haver- 
sian systems are imperfectly developed. They are irregular in 
shape and sometimes lobulated, but the location of the tumor and 
the bony resistance offered to its growth largely control its contour. 
It is usually single. 

Symptoms. — The early symptoms of osteoma may be those of 
a sinus-lesion, the nasal symptoms being due to irritation reflected 
from the site of origin. The pain, which will be present early 
and continue until the nerves from pressure cease to transmit 
sensation, is usually severe. As the tumor is generally situated in 
the upper portion of the nasal chamber, its presence will rapidly 
cause a deformity. Owing to the pressure, there will be some 
engorgement and congestion externally opposite the greatest point 
of pressure. The growth may extend upward through the ethmoid 
cells, invade the orbit, and press on the eyeball. The obstruction 
to nasal respiration will depend entirely on the size and location of 
the tumor. As a rule, there is considerable discharge from the 
nostril, which at times is very offensive ; but this will also depend 
on the location of the tumor, as to whether by its presence it causes 
accumulation of secretion. 

Diagnosis. — The presence of the tumor is easily recognizable, 
and its bony character can be determined by probe-palpation. As 
the simple osteoma is usually of slow development, should there 
be any tendency to rapid growth, the question of a sarcomatous 
element must be considered. This can be established by the 
removal of a small portion for microscopic examination. Even 
this procedure may be a source of error in this variety of tumor, 
for, if the osteoma is undergoing any sarcomatous change, it will 
be at the base of the tumor and not at the apex, where the portion 
for examination would likely be removed. Rhinoliths have no 
mucous-membrane covering, but may become encysted. 

Prognosis. — The prognosis is fairly favorable in the majority 
of cases, owing to the fact that attention is directed to the tumor 
early in its growth on account of the tendency to deformity as well 
as the existing pain from pressure. Should the tumor not be 
removed until serious facial deformity has been produced or until 
adjacent cavities have been invaded, the prognosis is not so good. 

Treatment. — If removal is attempted early, it may be done 



256 NEOPLASMS OF THE RESPIRATORY TRACT. 

through the nares by means of bone-cutting forceps (Fig. 67), saw 
(Fig. 53), or gouge. Yet in the majority of cases, as the tumor 
originates in the accessory cavities, it will necessitate an external 
operation for its complete removal. 

Remarks. — The nasopharynx, pharynx, and larynx seem to be immune to this 
form of tumor-invasion, as no cases have been reported occurring in these locations. 

MYXOMA (NASAL POLYPUS). 

Myxoma is one of the lowest grade of adult connective-tis- 
sue tumors, having its type in Wharton's jelly and the vitreous 
humor of the eye. When occurring in the upper respiratory tract, 
especially in the nasal passages, some confusion in the nomen- 
clature as well as the literature on the subject has been brought 
about by the fact that mucoid and myxomatous degeneration of 
pre-existing structure has been confused with an actual neoplasm. 
There is no question that myxomatous degeneration does take 
place in the mucous membrane lining the dependent portion of 
the turbinate bone, especially the middle. That from passive 
congestion and subsequent watery infiltration into the connective- 
tissue spaces, followed by absorption into the actual connective- 
tissue cells, there is brought about a hydropic degeneration in some 
cells and myxomatous or gelatinous change in others, giving rise to 
a polypoid-like growth, is also admitted. The same condition may 
also be brought about by a simple chronic form of inflammation. 

Etiology. — The myxomata, simple or mixed, are the most 
common of all nasal tumors. Many theories have been advanced 
as to their etiology, but personally I believe it to be the same as 
for any other benign connective-tissue tumor ; there is no definite 
cause known, at least there seems to be no one specific cause. Some 
maintain that myxoma is due to an inflammatory process, but from 
my own experience I believe the inflammation and catarrhal con- 
dition, in a majority of cases, are secondary to the tumor. ' With 
the formation of nasal myxoma there is frequently an associated 
infectious process or lesion of the accessory sinuses. The growths 
may be associated with necrosis of the ethmoid cells, or may 
originate in any of the accessory sinuses, and project thence 
into the nasal cavity. The theory that the tumor is caused by 
gravity and respiratory suction is a faulty one, as the current 
of respiratory air exerts as much pressure on the membrane 
as it does suction, and the result would be nil. Gravity may 
exert some influence as an etiological factor in producing the 
pedicle, but is not a factor in the formation of the tumor. 
That the mucous membrane surrounding the tumor is more 
or less inflamed and edematous is explained by the fact that 
the tumor is a foreign body, and necessarily causes a certain 
amount of accumulation of secretion, with secondary inflamma- 



MYXOMA. 257 

tion, although inflammatory conditions of the nasal mucous 
membrane in many cases exists before the formation of the 
polyp and is an exciting etiological factor. While age and sex 
do not exert any particular influence, myxoma is found to be 
more common between the ages of fifteen and thirty. The 
tumor may be single, but is more commonly found multiple. It 
is more frequently pedunculated than sessile. The sessile variety 
is more difficult of removal, and more likely to recur and become 
the site of a sarcomatous growth. The myxomata may be found 
in one or both nasal cavities. If the cavities are of unequal size 
owing to deflected septum, the tumor will usually be located in 
the larger nostril ; and should the constriction and narrowing in 
the smaller nostril be anterior, the growths will be situated poste- 
riorly behind the obstruction. The pure myxomata are markedly 
influenced by barometric change, the size of the tumor being greatly 
increased in damp weather, with the same marked diminution in 
dry weather. Cold and heat have little or no effect in altering 
the size of the tumor. The general systemic condition seems to 
have little influence as a causative factor, yet at the same time the 
individual usually manifests some systemic derangement, though 
in rare cases seems to be in perfect health. It must be remem- 
bered, however, that the apparent ill-health associated with 
the nasal polyp may be entirely due to the interference with nasal 
respiration, and is in no sense a causative factor. While myxoma 
may spring from any part of the nasal cavity, its common site is 
the middle turbinate bone. The size and shape of the tumor, 
whether it be pedunculated or sessile, single or multiple, depend 
largely on its location. The growth may be so large as to project 
from the nasal orifice. In such cases, the pedicle is usually long 
and thread-like. I have seen 3 cases in which the polyp was 
single and sprang from the floor of the nose, with a long thread- 
like pedicle, which allowed free movement to and fro in the nos- 
tril. When the turbinated bone is large and shelf-like, the tumor 
often springs from its under surface — a fact to be remembered 
when removal of the tumor is attempted. The color of a myxoma 
is grayish and translucent, and on probe-palpation the growth is 
springy, giving a sensation of fluid-resistance. The surface is 
usually smooth and shows distended and clearly outlined blood- 
vessels. At times the tumors may be irregular, and wave-like 
projections may be seen, as in the papillary edematous polypi, 
which are nothing more than an elongation of the row of epithe- 
lial cells on the surface, instead of an increase in the number of 
layers. The growth may spring from any portion of the nasal 
cavity, from the septal or turbinal side, the floor or the roof, the 
anterior or the posterior extremities. The size varies from that 
of a pin-head to proportions sufficiently large to include the entire 
nares or nasopharynx. When originating in the floor of the nose 
17 



258 



NEOPLASMS OF THE RESPIRATORY TRACT. 



or septum, niyxomata are usually single. When on the middle 
turbinate or above that structure, either anteriorly or posteriorly, 




Fig. 81.— Angiofibromyxoma, slightly fibrous (blood-polyp). 

they are most commonly multiple. Where the growth occurs on 
the septum, it is usually of the mixed variety, angiofibromyxoma 
(bleeding polyp; Fig. 81). 

Pathology. — Myxoma may be nothing more than a thin sac 
of connective tissue with its epithelial covering (Fig. 82), contain- 
ing fluid highly mucoid in character, with peculiar spindle-shaped 




Fig. 82.— Section of polyp (myxoma) : a, epithelial surface shown intact ; &, basement 
membrane ; c, polyp-structure. The portion directly underneath the mucous membrane 
shows more fibrous structure than the body of the polyp, it being simply a network of 
bipolar cells with fine trabeculse of tissue. The polyp was preserved intact, hardened in 
formalin, and embedded in paraffin, so that the sections were obtained with practically no 
change in the contour and structure of the tumor. 

cells and fine trabeculse of connective tissue. However, there is 
in most cases a considerable amount of fibrous connective-tissue 



MYXOMA. 259 

stroma present ; indeed, there are few pure myxomata, the major- 
ity being, in reality, mixed tumors — myxofibromata. This, how- 
ever, should not prevent their being called myxomata, because for 
the same reason the adenomata could be excluded, as these tumors 
always contain fibrous tissue, and are, in reality, adenofibromata. 
The blood-vessels are clearly outlined in the mucous membrane 
lining the tumor, although the blood-supply seems to course around 
the surface of the growth, and rarely ever penetrates the tumor- 
mass. The same condition holds good for the nerve-filaments, 
although in some cases these do not seem to be present, as the 
tumor may be removed without the use of any local anesthetic, 
and the patient experience no pain whatever. In other cases 
the presence of nerve-filaments is clearly demonstrated by the 
excessive pain when the growth is torn free. 

Symptoms. — The symptoms vary with the size, number, and 
location of the tumors. The voice lacks nasal resonance, having 
the peculiar nasal twang characteristic of nasal obstruction. 
There is usually considerable discharge, which may or may not be 
offensive in character, depending entirely on associated conditions. 
For example, with ethmoid necrosis the ozena will be quite marked. 
There will be associated considerable irritation of the pharynx 
and larynx, owing to the fact that the patient will be, of necessity, 
a mouth-breather. There will also be complaint of dryness of 
the mouth. The obstruction in the nostril is markedly increased 
in damp weather. If the tumor is high up in the nasal tract, it 
may obstruct the lacrimal duct and give rise to eye-symptoms. 
The tumor, either multiple or single, may assume sufficient size 
to cause marked facial deformity. By its presence the tumor 
may obstruct the opening into the antrum of Highmore and 
produce antral complications. JSasal myxoma may give rise to 
peculiar reflex neuroses, asthma, laryngeal cough, etc. This is 
especially true of the small single tumor situated high up in the 
nasal tract. I have seen several cases in which there was a 
marked asthmatic condition, with persistent " non-relievable " 
cough, which was almost instantly relieved by the removal of 
small nasal polypi. Owing to the pressure produced by the tumor 
over the olfactory fissure, there is nearly always impairment of 
the sense of smell It must be remembered that a nasal myxoma 
is, in reality, a foreign body, and that the symptomatology there- 
fore varies in individual cases, according to the location and size 
of the growth. 

Diagnosis. — This can easily be determined by inspection and 
probe-palpation. The posterior part of the anterior cavity should 
be carefully inspected, especially in the upper third, as the tumor 
may be small and easily overlooked. There is frequently found 
on the inferior border of the superior turbinate, especially if it be 
one of the long, projecting variety, the so-called polypoid hyper tro- 



260 



NEOPLASMS OF THE RESPIRATORY TRACT. 



phy, which is nothing more than a myxomatous or mucoid degener- 
ation occurring in association with, or following, simple chronic 




Fig. 83.— Sajous' nasal snare. 

or hyperplastic rhinitis. This should not be mistaken for pure 
myxoma. 

Prognosis. — The prognosis is good, except for a marked ten- 
dency to occurrence of other myxomata near the original site. 

Treatment. — The main object of treatment is the adoption 
of a method for the complete removal of the tumor without injury 
to the surrounding structure. This can be best accomplished by 
the cold- wire snare. The tumors may be removed en masse or 
singly. If the tumor is pedunculated, I prefer the modified 
Sajous snare as shown in Fig. 83, or the alligator-jaw biting- 
forceps ; the Jarvis snare, while good, is not equal to the Sajous. 
The nostril should be carefully cleansed after the operation, three 
or four times daily, with the aqueous solution of hamamelis and 
cinnamon water in equal parts. It is not necessary in all cases 
to use any stronger solution on the cut surface. However, 
should the bleeding be severe, it may be controlled by the 
application of an 8 to 10 per cent, solution of alumnol. After 
removal of the tumor, should any partially detached portions of 
tissue remain, they should be removed by the scissors shown in 
Fig. 76 or 84. Much has been written in regard to the recur- 
rence of these tumors. In my own experience I have never seen 
one of these tumors recur from the site of removal. There is a 
marked tendency, however, to the formation of a new growth, 
which I believe in many cases to have previously existed, simply 
held in abeyance by pressure. In some cases this, however, is not 
true, and there may be no further formation of tumors for months 
or even years. Where this tendency of re-formation exists, nothing 
more than theoretical explanations can be offered, as the origin 
of the tumor is controlled by the same unknown law which governs 
all benign growths. If the middle turbinated bone be large and 



FIBROUS NASAL POLYP, OB MYXOFIBROMA. 261 

shelving and its mucous-membrane covering thickened and boggy, 
the mucous membrane should be dissected up and the shelving 




Fig. 84. — Polyp-scissors. 

portion of the bone removed. Should any irregularity in the 
nasal passage exist, it should be corrected, if possible. By these 
means, possibly, a new supply of growths may be obviated. 

As to the use of caustics on the affected area, for the base or 
stump of the original tumor cannot be accurately located, I but 
mention them to advise against their use. The procedure is irra- 
tional because the exact spot to be cauterized cannot be located, 
and a certain amount of healthy mucous membrane is subjected to 
treatment not only unnecessary, but which might supply sufficient 
amount of trauma or irritation to stimulate return of the growth 
or malignant change. 

FIBROUS NASAL POLYP, OR MYXOFIBROMA. 

Fibrous polyp, or myxofibroma, is in reality a myxoma contain- 
ing a fibrous connective-tissue framework. 

Etiology. — The etiology of this growth does not differ from 
that of the pure myxoma. It most commonly occurs between the 
ages of twenty and thirty, and is exceedingly rare in children and 
in the aged. The earliest age at which I have seen it occur was 
in a boy of ten years. The right nostril contained two small 
polypi springing from the middle third of the middle turbinated 
bone. The fibrous myxoma is more commonly sessile than pedun- 
culated. It is more highly vascular than the simple myxoma, 
hence there is greater tendency to bleed on removal. The tumor 
involves deeper structure than the ordinary myxoma. I believe, 
in a myxofibroma in which there is a tendency to re-formation 
from adjacent structure, that the tendency is marked by the devel- 
opment of sarcoma (myxosarcoma), especially when the tumor has 
been removed frequently and with much laceration of tissue. Fig. 



262 NEOPLASMS OF THE RESPIRATORY TRACT. 

85 shows such a tumor. I do not mean to imply that the tumor 
degenerates into sarcoma, but that it becomes a suitable nidus for 




Fig. 85.— Myxosarcoma, a, Sarcomatous tissue ; b, blood-vessel ; c, myxomatous struct- 
ure, showing small round sarcoma cells infiltrating the tissue. 

the development of this malignant growth. The growth varies in 
shape and size, and may be single or multiple. They rarely ever 
spring from the septum or the floor of the nose. 

Pathology. — The microscopic appearance of the tumor differs 
from the ordinary myxoma only in the amount of fibrous con- 
nective-tissue stroma, which is usually of the loose wavy variety. 
If this variety of tumor — the fibromyxoma or myxofibroma — be 
removed, they all contain fibrous tissue in greater proportions on 
recurrence than was found in the original growth. 

Symptoms. — The symptoms caused by these growths are 
identical with those mentioned under Myxoma, and need not 
be repeated. 

Diagnosis. — The differential diagnosis between the myxoma 
and fibromyxoma depends largely upon the microscopic findings. 

Prognosis. — The prognosis is fairly good. There is a ten- 
dency to recurrence. It should also be remembered that it may 
become the site of sarcomatous growth (Fig. 85). 

Treatment. — Medical. — Good results have been obtained by 
the injection into the tumor of from 1 to 5 drops of the perchlorid 
of iron, or a few drops of a 3 per cent, solution of chlorid of zinc 
may be employed in the same way. The size of the tumor and 
their effect will control the number of injections ; usually from 
four to six, at intervals of from three to six days, are required to 
obtain a good result. Five per cent, chromic-acid and 3 per cent, 
nitrate-of-silver solutions are also highly recommended as injec- 
tions. My own experience has been highly unsatisfactory with 
this plan of procedure. 

I prefer to remove the tumor by means of the cold-wire snare 
(Fig. 83) or the alligator-jaw biting-forceps (Fig. 52), preserving 
as much as possible of the healthy surrounding mucous membrane. 



FIBROMYXOMA OF THE NASOPHARYNX. 263 

The wound produced by the removal of the tumor will require 
from three or four days to two weeks in healing. The nostril 
should be kept thoroughly cleansed by means of an alkaline anti- 
septic wash, such as : 

Jfy. Sodii biboratis, gr. xv (.9) ; 

Acidi carbolici, gr. ij (.12) ; 

Aquae cinnamomi, fl^ij (7.2) ; 

Aquae, q. s. ad flgj (30.). — M. 

Should much hemorrhage occur, it will be necessary to pack 
the nostril. This should be done with cotton pledgets saturated 
with hydrogen peroxid. 

FIBROMYXOMA OF THE NASOPHARYNX. 

The etiology of fibromyxoma of the nasopharynx is still 
somewhat speculative, but the pathology and site are well known. 
Simple fibromyxoma may spring from and be located purely in 
the nasopharyngeal space. Its common site of origin is from 
the basilar process of the occipital bone, a location from which 
it slowly but surely spreads. There seems to be no law con- 
trolling the rate or direction of its growth. It may extend 
upward, producing displacement of bony structure to such an ex- 
tent as to demand prompt and thorough surgical interference. 
On extending downward it may fill the nasopharyngeal space 
and even involve the pharynx. 

The symptoms will be controlled by the extent of the growth 
and the line of involvement. If the tendency is downward, 
there will be early impairment of the voice-resonance, the sen- 
sation as of the presence of a body in the pharynx, causing 
continuous swallowing, sensitiveness of the surrounding parts, 
and slight tendency to hemorrhage, and the individual will 
have a gaping appearance, owing to the necessitated mouth-breath- 
ing. When the tumor extends downward there will be inter- 
ference with the normal faucial movements ; owing to the obstruc- 
tion and some partial paralysis from the pressure there will be 
loss of motion of the soft palate and uvula. If the growth 
extends upward and reaches sufficient size, disfigurement of the 
adjacent structures may take place. There is usually persistent 
headache and a feeling of pressure over the bridge of the nose. 
The morbid histology of. the tumor in this location differs from 
that found in the nasal cavity only in the fact that there are 
more bundles of fibers and fewer individual stellate cells. This 
is probably due to the fact that in the nasopharynx and fauces 
there is more connective tissue present. 

The common symptoms of a nasopharyngeal growth of this 
size are inability to breathe through the nose, fulness in the head, 



264 NEOPLASMS OF THE RESPIRATORY TRACT. 

with the characteristic nasal twang ; difficulty in swallowing ; 
choking sensations ; deafness and tinnitus. 

Symptoms. — There is usually considerable catarrhal dis- 
charge both from the anterior nares and the nasopharynx. The 
accessory cavities may or may not be involved. I have seen 
a number of nasopharyngeal fibromyxomata, and each produced 
a different line of symptoms. In one particular case there were 
no associated symptoms evidencing any involvement of the acces- 
sory cavities or the ear. There was marked displacement of the 
bony structure of the nose on account of the pressure, and the 
symptoms were all directed toward the point of pressure — the 
bridge of the nose at the inner corner of the eye. One nostril 
was completely obstructed by the tumor-mass and the other 
was completely occluded, owing to the septum having been soft- 
ened, inflamed, and deflected, so as to completely occlude the nos- 
tril. Where there are a number of tumors present one may pro- 
trude into the nasopharynx and the others trend forward and 
block the nostril, while in other instances the nostrils are not in- 
volved and the entire mass is located in the nasopharynx. In 
other words, the tumor does not always follow the line of least 
resistance. In some cases there is considerable hemorrhage, while 
in others there is practically none. In the instance in which the 
tumors, as shown in Fig. 86, were removed there was practically 




Fig. 86.— Fibromyxoma removed from the nasopharynx. 

no hemorrhage and very little pain. In fact the only symptoms 
were the discomfort to the patient, owing to the fact that he could 
not breathe through his nose and the pain at the point of pressure 
and displacement. 



MUCOCELE. 265 



MUCOCELE. 



Synonyms. — Gelatinous or Mucous polypi. 

Etiology. — While the appearance and the symptoms of the 
gelatinous polyp are practically those of an ordinary myxoma, it is 
in reality a retention-cyst, having its origin in the mucous glands. 
It is frequently associated with irregularities within the nasal 
cavity either of size or shape, such as deflection of the septum, 
enlarged or ill-formed turbinal bones, and cartilaginous or bony 
growths. 

Pathology. — The pathology is that of a retention-cyst. The 
wall has an epithelial lining, and the contents are fluid or semi- 
fluid, highly gelatinous, containing albumin and mucin. 

Symptoms. — The symptoms are largely those of nasal myoma. 
There is likely to be greater interference with circulation, owing 
to the sessile formation of the tumor. This may cause external 
swelling of the nose, with slight edema and complete or partial 
obliteration of the labionasal fold, giving a peculiar expressionless 
face. 

Diagnosis. — Mucocele is usually situated high up in the nasal 
chamber, and does not contract, cocain having no effect. The 
tumor is fixed, but fluctuates. 

The prognosis is good. 

Treatment. — Open and curet, removing the entire sac. Mop 
the surface with a 3 per cent, solution of chlorid of zinc, and keep 
the nostril thoroughly cleansed by means of hydrogen peroxid and 
cinnamon water in equal parts, used three times a day. 

Nasopharynx.- — These tumors occurring in the nasopharynx 
are usually associated with a similar condition occurring in the 
anterior nares. The etiology, pathology, and symptoms are prac- 
tically the same, except that there is likely to be involvement of 
the Eustachian tube with middle-ear disease. Pharyngeal, laryn- 
geal, and bronchial irritation will also be more marked. The 
tumor, when occurring in the nasopharynx, usually arises from the 
inferior and posterior border of the middle turbinate or the infe- 
rior posterior border of the inferior turbinate. The removal of 
the postnasal tumor may be effected by means of the curved 
cannula of the cold-wire snare (Fig. 83). In some instances I 
prefer to use for their removal the alligator-jaw biting-forceps, 
employing this through the nostril after locating the tumor by 
means of the rhinoscope. Frequently the position of the tumor 
will permit its removal with the straight cannula of the cold-wire 
snare. 

I^arynx. — Under Myxoma of the Larynx will be considered 
not only the pure variety, but the mixed form — that is the myxo- 
fibroma and fibromyxoma, as clinically they are practically iden- 
tical, differing only slightly in their histologic appearance. The 



266 NEOPLASMS OF THE RESPIRATORY TRACT. 

growths, which vary in size, are usually single ; they may be 
sessile or pedunculated, more frequently the latter. They may 
spring from the vocal cords, either from above or below the saccu- 
lus, the epiglottis, the ventricular bands— in fact, from any portion 
of the larynx, though usually in its upper portion. In appear- 
ance they are somewhat translucent, of a pinkish-gray color, with 
clearly outlined blood-vessels on the surface. Myxomata fre- 
quently occur in middle life, and whether it be of any etiologic 
significance, it is more or less true they are most often found in 
persons who throw an unusual amount of strain on the voice by 
frequent use. This is a separate and distinct condition from what 
is known as " singers' nodes." There is little tendency to recur- 
rence after removal. When excessively fibrous they resemble 
papillomata very closely, and can be differentiated only by means 
of the microscope. 

Pathology. — The microscopic appearance of myxoma is prac- 
tically the same as given under Fibromyxoma of the Nares, 
except that when occurring in the larynx there is more of a 
fibrous capsule. 

Symptoms. — The symptoms are practically those of a mov- 
able foreign body. There may be alteration in the tone and char- 
acter of the voice, without complete loss. If the tumor is located 
below the vocal cords and movable, there Avill be spasmodic inter- 
ruption in phonation, owing to the fact that, in exhaling, the 
tumor may be forced up into the vocal bands. Depending on the 
size of the growth, the breathing may become difficult, even to the 
point of threatened dyspnea. This symptom may become suffi- 
ciently alarming to warrant surgical interference by the perform- 
ance of tracheotomy. There is rarely any pain or hemorrhage, 
the main symptoms being those of obstruction and alteration in 
voice. 

Diagnosis. — Owing to the extreme sensibility of the parts, due 
to local irritation produced by the tumor, it may be difficult to 
obtain a thorough laryngoscopic view of the larynx, even after the 
use of cocain as a local anesthetic. From its appearance and 
attachment the diagnosis of benign tumor may be made, but its 
histologic nature must be determined by post-operative microscopic 
examination. 

Prognosis. — The prognosis depends on the size and location 
of the growth ; but, if recognized early, with prompt removal, in 
many cases complete return of the voice may be obtained, or at 
least the distressing symptoms relieved. 

Treatment. — The removal of laryngeal tumors is a delicate 
and difficult procedure, and should be attempted only by a skilful 
manipulator. Indeed, more permanent alteration may be caused 
by the careless use of cutting instruments than was actually caused 
by the growth. If the intralaryngeal operation can be done, 



CARCINOMA. . 267 

there should be used a local anesthetic, preferably cocain, and with 
the aid of the laryngeal mirror and the cutting laryngeal forceps 
the tumor may be removed. Under no consideration should the 
forceps be closed unless the cutting-blade and its relation to the 
growth be clearly outlined in the laryngeal mirror. 

EMBRYONIC EPITHELIAL TUMORS. 
CARCINOMA. 

Nasal Passage. — Carcinoma of the nasal passage usually 
occurs as the variety called squamous-celled epithelioma. It is 
rare, but when found is usually primary and invades the adjacent 
structure. It may have its origin at the mucocutaneous junctures, 
and involve not only the mucous-membrane structures, but extend 
externally. The growth usually begins as a small nodular infil- 
trated area, which extends rather rapidly and tends to ulcerate 
early. 

Etiology. — The cause of tumors is largely a matter of theory. 
The Cohnheim inclusion-theory — the one generally accepted — sup- 
poses that there is an excess of embryonic cells necessary to the 
construction of fetal tissue, and that these masses of latent embry- 
onic cells may be later in life stimulated to active proliferation. 
Carcinoma in all its varieties belongs to the epithelial type of 
tissue, and is embryonic. The so-called heredity is merely an 
inherited tendency, and can only predispose. It is a well-known 
clinical fact that constant irritation is an exciting factor in carci- 
noma, while trauma predisposes to sarcoma. This, at least partially, 
explains the tendency of benign growths to form the site of malig- 
nant growths when they are so located as to be subjected to con- 
stant irritation or trauma. This is not a change of type of tissue, 
but simply the formation of a suitable site for development. It 
is also a well-established clinical fact that physiological activity 
favors the development of sarcoma, while physical decline favors 
the development of carcinoma. As tissue never changes type, 
carcinoma must therefore have its origin in the epithelial or papil- 
lary surface, while sarcoma springs from the deeper or connective- 
tissue elements. Carcinoma of the nares usually begins in the 
anterior portion of the nose, which may be explained by the fact 
that these structures are the most exposed to irritation, although 
it is often difficult to give the exact location or origin of the 
tumor. 

Pathology. — The morbid anatomy or microscopic appearance 
will depend somewhat on the stage or development of the tumor. 
Occasionally, considerable normal tissue will be found present. 
This is due to the fact that carcinoma spreads by the lymphatics, 
thereby spreading irregularly. The real cause of the growth is 



268 NEOPLASMS OF THE RESPIRATORY TRACT. 

the proliferation of the embryonic^ epithelial cells which have 
invaded the normal structure, and the connective-tissue frame- 
work of the tumor is nothing more than the altered pre-existing 
tissue of the parts. The nests of epithelial cells vary in size as 
well as in the shape of the cell ; indeed*, it would be impossible to 
differentiate an individual cell from an ordinary connective-tissue 
cell, as the rapidity of growth and the amount of pressure on the 
cell or the resistance offered to growth will determine its shape 
and size. The nests of cells are surrounded by connective tissue, 
which in the early stage of development of the tumor resembles 
closely the normal connective tissue of the part; but, as the 
tumor develops, the connective-tissue stroma will become more 
fibrous and the tumor more firm, more closely resembling the 
variety known as scirrhous carcinoma. 

The blood-vessels will be always found in the connective-tissue 
stroma. Their walls are usually thickened, due rather to the 
change in the perivascular connective tissue than in the actual 
vessel-wall. 

Symptoms. — One of the earliest symptoms of carcinoma of the 
nose is the peculiarity of the pain, which, although irregularly so, 
is at times lancinating. While the pain is characteristic, it is not 
so severe or continuous as in carcinoma elsewhere. There is a 
mucopurulent discharge, which is almost characteristic in color 
and odor. There is usually some bleeding, although not so exten- 
sive as in sarcoma. Early in the disease there is not much inter- 
ference with nasal respiration, although later the obstruction may 
be marked. Occasionally the growth spreads to the ethmoid and 
sphenoid cells. When such is the case there is impairment of 
vision ; the growth may extend and enlarge sufficiently to cause 
protrusion of the eyeball. In primary carcinoma of the nose 
there is only slight lymphatic enlargement. When secondary, or 
associated with general carcinomatosis, there may be general gland- 
ular involvement. The ulceration is peculiarly deep and ragged, 
discharging a thin grayish-brown offensive material. With the 
progress of the growth there is increased cachexia. 

Diagnosis. — By inspection and from the clinical history alone, 
it may be difficult to establish the diagnosis of carcinoma, and it 
may be necessary to resort to the microscope for confirmation 
before extensive operative interference. Care should be exercised 
in the obtaining of this specimen, for two reasons : 1. That there 
should be as little laceration and irritation of the parts as possi- 
ble. 2. That the portion removed should not involve directly the 
ulcerated area, which will contain inflammatory embryonic con- 
nective tissue. As has been pointed out by J. Bland Sutton, this 
cannot be differentiated from sarcoma or from a simple inflam- 
matory process with ulceration. If, however, the specimen is 
taken early, before ulceration has occurred, this source of error 



CARCINOMA. 269 

may be obviated. Sufficient tissue should be removed to permit 
of a thorough and careful examination. The import of this exam- 
ination is too great to permit of any error of diagnosis, as the 
thoroughness of the surgical procedure is entirely controlled by 
whether it reveals malignancy or the opposite. In carcinoma the 
secretion does not adhere to the surface of the growth, while in 
tubercular lesion it is tenacious, stringy, and adheres. 

Prognosis. — The prognosis is grave. In some cases the extent 
of the lesion may be such as to render it inoperable, and, unless 
thorough eradication can be accomplished, it is better to leave the 
tumor alone, as clinical experience shows that partial or incom- 
plete removal tends to increase the growth and the dissemination 
of the tumor rather than to lessen it. 

Treatment. — The clinical data seem to show that operative 
procedures shorten rather than prolong life in advanced cases. If, 
however, the character of the growth is recognized early, prompt 
and thorough operative interference should be instituted. If the 
glandular involvement is marked, or if extensive and considerable 
ulceration has occurred, thorough cleansing with sedatives and 
palliative measures should be adopted. This should consist in the 
relief of the pain and the improvement, as far as possible, of the 
general condition of the patient. Locally, orthoform is a good 
sedative. Aristol, 20 grains to the ounce of stearate of zinc, 
should be dusted on the ulcerated area. The progress may be 
arrested by the use of acid applications, either the dilute nitric or 
hydrochloric, applied every other day. Lactic acid, I find, gives 
no better results. I have obtained quite beneficial results as to 
arresting the process elsewhere by a 5 per cent, formalin solution. 

Nasopharynx. — Primary carcinoma of the nasopharynx is a 
rare condition. When it does occur, most likely there is involve- 
ment of the soft palate, with extension into the pharyngeal struct- 
ures ; or the primary growth may be in the anterior nares, and 
extend by the lymphatics into the posterior nares. 

Symptoms. — The tumor is of rather slow development, giving 
rise to gradual interference with nasal respiration. At first, the 
pain is slight, gradually becoming more marked and reflected to a 
greater degree. There will be increased secretion, which, when 
ulceration occurs, will become mucopurulent and blood-stained. 
The gland-structure of the nasopharynx, the pharynx, and the 
cervical glands will become secondarily involved. 

Diagnosis. — Accurate diagnosis from this standpoint of a cura- 
tive treatment can be made only by a microscopic examination of 
a portion of the growth. 

Prognosis. — Carcinoma of the nasopharynx is usually fatal in 
from one to three years. 

Treatment. — The treatment consists largely in the attempted 
amelioration of the distressing symptoms. Radical operation will 



270 NEOPLASMS OF THE RESPIRATORY TRACT. 

be determined by the patient's condition, the character of the 
growth, and the structures involved. 

Soft Palate. — Carcinoma of the soft palate usually appears 
in the form of epithelioma, either cylindrical, squamous-celled, or 
tubulated. When occurring in this location, they usually do not 
appear before middle life, or, more often, until late in life. The 
question of the effect of sex is markedly illustrated in carcinoma 
of the soft palate, as from reported cases it is unquestionably more 
common in males than in females. This naturally brings up the 
question of chronic irritation, such as would be produced by 
overindulgence in smoking or by the continuous chewing of 
tobacco. This I do not believe to be an exciting factor always, 
as I have seen several cases in which the individual did not use 
and never had used tobacco. 

Carcinoma of the uvula or soft palate has its origin in the 
muciparous glands found in this tissue. Hence the most common 
variety is that known as the tubulated epithelioma. In other 
parts of the body, the tubulated variety of epithelioma occurs 
earlier in life than the other varieties. This does not seem to be 
true of the soft palate. Carcinoma of the soft palate is usually 
primary, and in many cases limited to the soft palate, although 
occasionally, late in the disease, it does extend to the adjacent 
structures — usually the pillars, both anterior and posterior. 
Another peculiarity of carcinoma in this location is that on its 
removal there is an early recurrence. The tendency to spread is 
somewhat controlled by the location, or rather the origin of the 
tumor. If it has its origin in the tonsillar gland-structure, there 
is a marked tendency to spread by the lymphatics. If, however, 
it has its origin in the muciparous glands, the tendency to spread 
is much less. This is due to the fact that the tumor, having its 
origin in the epithelial lining of the gland or of its duct, the 
growth will at first be confined within the lumen of the tubule. 
By the distention thus caused by the cell-proliferation, the lym- 
phatic system is largely interfered with by pressure, and by the 
time the embryonic epithelial cell invades the surrounding struct- 
ure owing to this pressure, the tendency to spread by the lym- 
phatics is at its minimum. Whether the tumor begins purely as a 
malignant growth, or whether it be a papilloma which has been 
the site of a malignant change, does not alter the prognosis or 
treatment. There is a condition, which is frequently observed on 
the anterior border of the soft palate, which is known as leuko- 
plakia buccalis, in which there are minute areas varying in size 
from a pin-head in diameter to as large as a ten-cent piece. The 
white areas seem to be brought about by fatty degeneration in the 
surface-epithelium, which seems to be largely due to local inter- 
ference with blood-supply. While the condition itself is not car- 
cinomatous, yet it seems to bear the same relation to carcinoma 



CARCINOMA, 271 

as Paget's disease of the nipple does to carcinoma of the breast. 
Although this condition is rarely found on the soft palate, and 
spots resembling it very much may appear there, associated with 
diseases of the stomach, yet if the condition persists and there is 
desquamation, it should always be looked on as suspicious. 

Symptoms. — The early symptom of carcinoma involving the 
soft palate is a loss of free movement of the palate. As the tumor 
advances in size, this becomes more marked and increases the 
faulty action of the soft palate, permitting the food to regurgitate in 
the nasopharynx. There is faulty phonation, which is at first largely 
due to the impaired nasal resonance, but later may be increased by 
the congestion brought about by interference in the venous circu- 
lation. The mucous membrane covering the adjacent structures 
may be slightly inflamed, with slight edema of surrounding struct- 
ures. Should the tumor invade the adjacent tissue and reach a 
size large enough to produce mechanical laryngeal obstruction, the 
dyspnea produced may be so serious as to necessitate tracheotomy. 
The pain is irregular and usually not severe, unless it is late in the 
growth and there is marked involvement of adjacent structures. 
This is possibly due to the yielding character of these tissues, there 
being very little bony resistance. In primary carcinoma involving 
the soft palate, there is no marked tendency to ulcerate. This is 
possibly due to the double vascularity of the part and to the fact 
that carcinoma is usually of the variety known as tubulated epi- 
thelioma, wdiich is not so liable to ulceration. 

Should recurrence of the tumor take place, there are usually 
ulceration and hemorrhage, the recurrent variety, as a rule, being 
more of the scirrhous variety than any of the other forms of 
epithelioma. With recurrence there is usually marked enlarge- 
ment of the cervical glands. However, in primary carcinoma 
such involvement does occur, though not always. The patient 
gradually assumes the cancerous cachexia. 

Diagnosis. — The differentiation between carcinoma, papilloma, 
and adenofibroma can be reliably accomplished only by means of the 
microscope. 

Prognosis. — In the majority of cases the prognosis is fatal, 
although operation may prolong life, as recurrence may not take 
place in from a few r months to a year. 

Treatment. — The result of operative treatment, other than for 
palliative purposes, seems to be negative. 

Pharynx. — Carcinoma of the pharynx is rarely ever limited 
strictly to that structure ; in most cases the adjacent tissues, either 
the tonsil, the soft palate, or the nasopharyngeal structure, are 
associated in the involvement. Frequently, carcinoma of the 
pharynx is associated with that of the esophagus. It usually 
begins on the posterior walls and follows the course of the 
lymphatics, and extends around the lateral and anterior walls. 



272 



NEOPLASMS OF THE RESPIRATORY TRACT. 



Carcinoma occurring in this location is usually of the squa- 
mous-celled epithelial variety, but the scirrhous variety has been 
observed. 

Symptoms. — Early in the growth of the tumor there is little 
pain, but with ulceration, which comes on rapidly in carcinoma in 
this location, pain will become one of the chief symptoms. This 
pain is increased on swallowing, especially when taking food, 
and is of a lancinating, radiating character. Phonation is imper- 
fect. Expectoration is profuse and, after ulceration, becomes 
white, fetid, and offensive. If the carcinoma be of the epithelial 
variety, the growth is soft and spongy in character ; or if of the 
scirrhous variety, it begins as a hard, irregularly outlined mass. In 
either form, early in the growth the mucous-membrane surface is 
fairly normal in appearance ; but with ulceration this is entirely 
lost. The cervical glands are involved, and in the scirrhous 
variety this involvement takes place early. If the growth occurs 
low down in the pharynx and is limited to the posterior surface, it 
is more often of the fungoid character. It is very irregular in 
outline, and the surrounding structures are swollen almost to the 
point of being edematous. In low involvement of the pharynx 
there is not such marked implication of the cervical glands. 

Diagnosis. — 

SYPHILIS. 

May be manifestations 
elsewhere; ulceration may- 
be single or multiple. 

Indurated. 

Fairly firm, with sur- 
rounding areas of inflam- 
mation. 

Ulceration. 

Tends to heal. 



CARCINOMA. 

May be limited to 
pharynx, but likely to in- 
vade adjacent structure. 

Sessile. 

Irregularly firm. 



Ulceration. 

Ulcer does not tend to 
heal. 

Not affected by reme- 
dial agents. 

Pain severe. 



FIBROMA. 

Limited to pharynx ; 
no involvement of ad- 
jacent structure. 

Pedunculated. 

Dense and firm. 



No ulceration. 



Not affected by reme- 
dial agents. 
No pain. 



Responds to thera- 
peutic test. 

Pain on irritation. 



Prognosis. — Unfortunately grave and fatal. 

Treatment. — The treatment is largely palliative, as no radical 
operation can be successfully performed. If the tumor attains 
sufficient size to interfere with deglutition, a portion may be 
removed to lessen such interference, but such operative pro- 
cedure tends to irritate the growth rather than relieve. 

Tonsil. — Carcinoma of the tonsil is rather a rare lesion. 
When it does occur, it is generally in the form of the squamous- or 
cylindrical-cell epithelioma. It is rarely ever a primary growth, 
usually extending to the tonsil from the tongue or the pillars of 
the fauces. In epithelioma of the tonsil ulcerations occur, and 
the cervical glands are involved early. Carcinoma in this loca- 
tion rarely occurs under forty, but some cases have been re- 



CARCINOMA. 27 S 

ported as early as thirty. The tumor is not usually of large size, 
but tends to involve the adjacent structures rapidly — if primary, 
of the tonsil, although in the majority of cases the adjacent struct- 
ures are the first involved. The ulceration which occurs in this 
variety of carcinoma is accompanied by a characteristic odor that 
cannot be described, but is recognizable even by the laity. The 
patient shows the cachexia peculiar to wasting diseases and mal- 
nutrition. There is excessive secretion, which, as ulceration 
advances, becomes almost purulent and is highly irritating. The 
pain is marked, and increased by deglutition. Should the tumor 
invade deeper structures and involve the greater vessels, severe 
and even fatal hemorrhage may result. With the progress of the 
tumor the cachexia increases, with a tendency to edema of the 
glottis. There is marked alteration in the voice. 

The treatment is the same as given under Sarcoma, and does 
not necessitate repetition. 

I/arynx. — In differentiating laryngeal growths a hurried 
diagnosis of carcinoma of the larynx should never be made. It 
must be remembered that the larynx is a common site in the man- 
ifestation of a latent specific lesion, and it is always advisable 
before making a diagnosis of carcinoma of the larynx to study the 
case carefully and eliminate the possibility of a specific lesion by 
means of the Wassermann reaction and the therapeutic test (see 
pages 592 and 698). 

There is a vast difference of opinion in regard to malignant 
growths of the larynx, especially in the form of carcinoma, 
centering on the question of the growth being always primar- 
ily malignant. It is a matter that is. always open for discus- 
sion, and in many cases can never be settled from a microscopic 
standpoint. For example, a carcinoma in any of its varieties may 
originate in the larynx, showing a nodular papillary surface, and 
the clinical diagnosis of papilloma may be made. As the tumor 
progresses and shows its true nature, it may be clinically stated 
that it was a papilloma which had undergone carcinomatous 
change. On the other hand, the growth may have been primarily 
a benign tumor — papilloma — which, either from the irritation due 
to attempted removal or from mechanical irritation due to its loca- 
tion, may be the site of a malignant growth. I do not mean by 
this that it " turns into a carcinoma/' because tissue never changes 
type, but that, as it is a low grade of adult tissue, it would be a 
suitable nidus for the development of carcinoma. Personally, I 
believe that either condition may occur, and the great diversity of 
opinion is largely due to the fact that rarely, if ever, is a micro- 
scopic examination made early in the growth ; and without such 
examination the question of secondary change cannot be deter- 
mined. This was especially true in the famous case of the 
Emperor Frederick of Germany. That a papilloma may be the 
site of a carcinomatous growth is illustrated in the case that was 

18 



274 NEOPLASMS OF THE RESPIRATORY TRACT. 

reported by Dr. M. R. Ward of Pittsburg, in which the primary 
papilloma was removed, sections made, and microscopic diagnosis 




Fig. 87.— Section of carcinomatous tissue from larynx : a, nests of epithelial cells ; b, 
fibrous tissue ; c, where clusters of cells had dropped out in handling the section. 

of papilloma given. Later, a growth appeared in the larynx which 
necessitated laryngectomy ; and microscopic examination proved 
it to be carcinoma of the tubulated or adenoid variety (Fig. 87). 
The fact that the carcinoma developed in the same structure does 
not prove that it was a recurrence of the pre-existing growth, 
which may have been merely the predisposing or exciting cause. 

An error in diagnosis, even microscopical, can easily be made 
in malignant growths of the larynx, because frequently the epi- 
thelioma has a papillomatous surface, and a minute piece removed 
for the purpose of microscopical examination may remove only these 
papillomatous nodules. This is clearly demonstrated in a case of 
Professor Keen's, in which clinically and from laryngeal examina- 
tion the tumor was undoubtedly malignant, although a minute 
portion removed for microscopical examination showed typical 
papillomatous growths which were only papillomatous projections 
from a carcinomatous growth (Fig. 88). After partial laryngec- 
tomy and removal of the entire tissue, microscopical examination 
of the mass of the tumor showed it to be clearly carcinomatous 
(Fig. 89). This, however, does not disprove the fact that a growth 
may be originally papillomatous and afterward the site of malig- 
nant change. 



CARCINOMA. 



275 



Sex seems to exert some influence, as carcinoma of the larynx 
occurs more frequently in males than in females. In about 25 per 




Fig. 88.— Section of papillomatous growth from vocal cord (author's section). This is 
taken from one of a number of papillomatous projections from a mass involving the right 
vocal cord and infiltrating the tissue below. This portion was removed by means of biting- 
forceps, for the purpose of microscopic examination. From all appearances, it is papillo- 
matous ; but clinically it had the history and appearance of carcinoma. Subsequent laryn- 
gectomy proved it to be carcinoma, as shown in Fig. 78, this tissue merely being a papillo- 
matous projection on the mucous-membrane surface of the carcinoma, showing how easily 
the mistaken diagnosis of papilloma followed by carcinomatous change might be made. 

cent, of the cases there is an inherited tendency. Alteration in 
voice, which is sometimes attributed to overuse and laryngeal 




Fig. 89.— Epithelioma of the larynx (Keen's case). 

catarrh, given as exciting factors, are in reality only early symp- 
toms. 

Pathology. — Carcinoma of the larynx usually occurs as one 
of the epithelial varieties, most commonly the squamous-celled or 
tubulated form. The tubulated form is in reality adenocarcinoma. 



276 NEOPLASMS OF THE RESPIRATORY TRACT. 

The tumor may have its origin in any part of the larynx, but is 
most commonly situated primarily in the ventricular bands, vocal 
cords, or epiglottis. The involvement of surrounding structures 
depends on the primary location of the tumor. If it is first within 
the larynx — the intrinsic form — as a rule, it does not involve the 
surrounding structure, and the glands of the neck are not impli- 
cated ; this is possibly due to the fact that, owing to location, the 
tumor proves fatal before such involvement takes place. If, how- 
ever, it involves the epiglottis, or is extrinsic, the adjacent struct- 
ures will be involved, and through the communicating lymphatics 
the glands of the neck will be enlarged, and are usually involved 
early in the disease. 

Symptoms. — The symptoms are necessarily somewhat those of 
a benign tumor, especially in the early stage of the carcinomatous 
growth. The early impairment of the voice will depend entirely 
on the location of the tumor. If the vocal cords and ventricular 
bands are the primary site of the growth, loss of voice will be 
one of the earliest symptoms. The alteration in the voice is rather 
characteristic, consisting in a change in the force rather than 
alteration in tone and register. As the tumor progresses, there 
may be marked dyspnea. If the growth is intrinsic, there may 
be some dysphagia, which will account for the excessive flow and 
accumulation of secretion in the mouth. There may or may not 
be glandular involvement. In the extrinsic variety, glandular 
involvement occurs early. In the intrinsic variety, if at all, it 
will be late. Ulceration usually takes place in from three to six 
months, which is rather early when compared with carcinoma in 
other locations. With the ulceration hemorrhage begins, which 
increases with the destructive process. The ulceration is not 
usually deep, but in some cases there may be involvement of the 
deeper structures, causing interstitial necrosis. In such cases the 
ulcer will be deep and irregular. This, however, does not occur 
except in the encephaloid variety, which is rare in the larynx. 
Before ulceration occurs, the secretion is excessive, but of a healthy 
character, caused rather by the presence of the growth than by its 
effect on circulation. However, after ulceration takes place, the 
secretion becomes more mucopurulent and tenacious. It may be 
slightly blood-streaked, grayish or greenish-brown in color, and 
contains pus-cells and necrotic tissue. The breath is almost char- 
acteristic, having a peculiarly offensive musty odor. Hemorrhage 
is usually not severe, although late in the growth, with marked 
ulceration, it may be of an alarming character. The pain begins 
early and is usually a constant symptom. When the grow T th is 
situated within the larynx, pain is not such an early symptom, nor 
is it so marked. However, if the growth is extrinsic, the pain is 
lancinating and radiating in character. In the intrinsic variety 
the cancerous cachexia is slight ; it is more marked in the extrinsic. 



CARCINOMA. 277 

Diagnosis. — The diagnosis of intralaryngeal growths is by no 
means easy. In the healthy larynx in some individuals it is very 
difficult to make a complete and satisfactory examination, while 
in a diseased larynx it is even more difficult, often requiring the 
greatest skill in manipulation to obtain even a partial view. How- 
ever, the location of the tumor, the ulcer, and the gland-involve- 
ment aid materially in the diagnosis. In some cases a small por- 
tion of the growth can be removed for microscopic examination. 
If this is done, care should be taken that the piece of tissue 
removed does not include the ulcerative process, for in such tissue 
but little can be determined from microscopic examination as to 
its malignancy. It must also be noted that proliferating epithe- 
lial cells on epithelial surface do not mean cancerous growth, but 
the proliferating epithelium must actually have invaded the con- 
nective-tissue structure and show proliferation there. As a rule, the 
secretion does not adhere to the tumor, the surface being practi- 
cally free from secretion, while in tubercular lesion it is tenacious, 
stringy, and adheres. 

Prognosis. — The prognosis is bad. In a large percentage of 
the cases in which operation has been done, and in over 10 per 
cent, of cases in which the primary operation afforded relief, 
recurrence has taken place. 

Treatment. — Early and radical operative procedure is the only 
curative measure that can be attempted, and, as statistics show, 
this is not at all a certainty. The distressing symptoms caused by 
the growth may be relieved by anodynes, and the parts should be 
thoroughly cleansed by disinfectant solutions. For keeping the 
parts thoroughly clean nothing is better than \ per cent, pyoktanin 
solution, the only disagreeable feature being that it stains blue all 
tissues with which it comes in contact. A 2 per cent, solution of 
permanganate of potash will largely lessen the disagreeable odor. 
If hydrogen peroxid should be used, the parts must first be 
cleansed with an alkaline solution, as the hydrogen peroxid w T ill 
cause coagulation of the material, making it very difficult of 
removal, especially when associated with the impaired muscular 
action due to the growth. Palliative results can be obtained by 
dusting the parts with cocainized iodol (containing 1 per cent, 
cocain). Equally good results may be obtained by dusting the 
ulcerated surface with morphin powder, although personally I 
prefer to use the drugs in solution, as the powders are more likely 
to produce irritation and cough. If the pain is very severe the 
affected area may be sprayed with a 5 to 10 per cent, solution of 
cocain, but this has to be repeated frequently. The hypodermic 
injection into the mass of the tumor of 1 : 1000 formaldehyd solution, 
the strength gradually increased to 1 : 500, has at least been bene- 
ficial in some cases, although the best results seem to be obtained 
by the rather deep injection of minute quantities around the border 



278 NEOPLASMS OF THE RESPIRATORY TRACT. 

of the tumor. The dyspnea ruay become so marked as to require 
palliative tracheotomy. Of the radical methods, endolaryngeal 
operations are least successful. Caustics and escharotics are to be 
carefully avoided, as they only irritate and do not have any cura- 
tive properties. The best surgical operation can be chosen from 
thyrotomy, resection, or complete extirpation (see Laryngectomy, 
page 797), according to the case. Thyrotomy gives a lower per- 
centage of successful terminations than either resection, complete 
extirpation, or Keen's method of partial or complete laryngectomy. 
In inoperable cases, any palliative measure that will give comfort 
to the patient is justifiable. 

As regards the x-ray treatment, the reports have been so 
meagre, the cases treated so few, and the time this method has 
been in vogue so short, that it is impossible at present to make 
any definite statement as to its value. Although no final and 
decided cure has been reported, the results obtained in the treat- 
ment of malignant disease elsewhere in the body, and the improve- 
ment that has been noted in the few laryngeal cases reported, 
would serve to justify its trial. As a general rule, the sc-ray 
treatment of deep-seated malignant disease has resulted less favor- 
ably than in cases of superficial lesions ; and the deep-lying posi- 
tion of a laryngeal neoplasm renders it, therefore, less amenable 
to this form of therapy than a similar lesion in a more advan- 
tageous situation. Further investigation and many more case 
reports are needed before an authoritative opinion can be ex- 
pressed. 

EMBRYONIC CONNECTIVE=TISSUE TUMORS. 

SARCOMA. 

Nasal Passage. — Primary sarcoma of the nose is not of fre- 
quent occurrence ; but, as a rule, it has its origin in the adjacent 
structures, and spreads thence into the nasal cavity. Like carci- 
noma, it raises the question of transition of benign growths into 
malignant, and the same rule as given under Carcinoma is appli- 
cable to sarcoma. Myxoma, which is the lowest grade of benign 
connective-tissue tumor, from trauma may be the site of sarcom- 
atous change. This fact does not at all show transition, as sar- 
coma may develop from a simple inflammatory tissue. Nasal sar- 
comata are of rather slow development, and may occur at any age 
and under any condition, although they are more common before 
forty. Sarcoma, involving the nasal structures, may have their 
primary seat in the ethmoid cells, or these cells may be secondarily 
involved by the extension of the growth. 

Pathology. — The tumor has its origin in the deep connective 
tissue, and spreads to the mucous surface. If the tumor is of 



SARCOMA. 279 

rapid growth, it is usually of the small round-celled variety (Fig. 
90). However, in this location sarcoma is usually of the large- 
cell variety and of slow growth. The mucous membrane covering 
the tumor is normal, the tumor usually coming from below. As 
the growth progresses, the mucous membrane will become thin- 
ner and the epithelial cells flattened. The tumor contains very 
little, if any, fibrous tissue, the cells being held together by a 
fibrinoplastic intercellular substance. Sarcoma is nodulated and 
fungoid in appearance, usually soft, almost semi-fluctuating, the 



Fig. 90.— Small round-celled sarcoma, a, Sarcomatous cells held together by intercel- 
lular material ; b, blood-vessels. The absence of organized connective-tissue is to be noted, 
showing the structure to be an entirely new growth, and not an infiltration. 

location and resistance offered to the growth determining its 
density. 

Symptoms. — The first symptoms of sarcoma of the nose are 
those of obstruction. Ulceration, which comes on late together 
with the vascularity of growth, will result in profuse hemorrhage. 
Before ulceration there is a discharge of a catarrhal nature, resem- 
bling that found in any obstruction to nasal breathing. After ulcer- 
ation the discharge becomes more mucopurulent, blood-stained, 
and is decidedly offensive in character. Deformity will depend 
entirely on the location of the tumor. The same can be said of 
the pain. If the tumor involves only the soft structure, the pain 
is, as a rule, slight ; but if tissues backed up by bony structure 
are involved, it will be severe. This is especially true when the 
tumor originates in, or secondarily involves, the accessory sinuses. 

Diagnosis. — Accurate diagnosis can be made only by the 
removal of a small portion and by a careful microscopic examina- 
tion. The tumor is soft and pseudofluctuating, highly vascular, 
and may affect any of the nasal structures, frequently involving 
the septum. While the microscopic examination is of the greatest 



280 NEOPLASMS OF THE RESPIRATORY TRACT. 

import, yet the clinical history must be taken into consideration 
in establishing a positive diagnosis. 

Prognosis. — As sarcoma is one of the malignant tumors, the 
prognosis is always grave ; although if the nature of the growth 
is recognized early, and the tumor is promptly removed, the prog- 
nosis is better when occurring in this location than in any other 
portion of the body. The early recognition of the tumor, its 
location and rapidity of growth, and the age of the individual 
must be taken into consideration in giving a prognosis. 

Treatment. — Early, complete, ~nd thorough eradication is the 
best plan of treatment. This can be accomplished by the curet or 
the galvanocautery. If removal is attempted at all, it must be 
thorough and complete, leaving absolutely none of the tumor- 
structure, otherwise the operation will only aggravate the growth. 
As sarcoma is highly vascular, there is danger of excessive hem- 
orrhage, which can be controlled by plugging the nostril with 
iodoform gauze. If the extent of the lesion is such as to involve 
adjacent structures, external operation will be necessary. 

Nasopharynx. — Etiology. — Sarcoma of the nasopharynx is 
not of common occurrence. It is found more frequently in males 
than in females, more often between the ages of forty and fifty than 
at any other time in life, although it may occur early in life, one 
case reported occurring at two years of age. The tumor has its 
origin in the submucosa of the mucous membrane lining the bas- 
ilar process of the occipital bone. The growth, which usually 
extends downward, is lobulated and irregular, and, as it is usu- 
ally of the small round-celled variety, extends rapidly and soon 
involves the pharynx. As a rule, the bony structures are not 
implicated, although in some cases such involvement does occur. 
The tumor is soft and fungoid in character and rapidly invades 
the lower pharynx, although it may extend upward and involve 
the sphenoid or sphenomaxillary sinuses. 

Symptoms. — The early symptoms are those most commonly 
found due to nasal obstruction. The discharge rapidly becomes 
oifensive and bloody. Ulceration and hemorrhage occur early. 
The general health is affected, due to interference with nasal respi- 
ration, as well as to the fact that deglutition is difficult. There is 
early impairment of hearing, owing to the involvement of the 
Eustachian orifices. The pain is not usually severe until the 
tumor has attained a size sufficiently large to cause pressure on 
adjacent structures. It is reflected and radiating. 

Diagnosis. — The diagnosis, which is rather difficult in some 
cases, can be based on the rapidity of the growth, its lobulated 
appearance, its soft (almost pultaceous) feeling, and its high vas- 
cularity. The removal of a small portion for microscopic exam- 
ination will materially aid in the diagnosis. 

Course and Prognosis. — In early life sarcoma runs a rapid 



SARCOMA. 281 

course, as it is usually of the small round-cell variety. If it be of 
the large-cell variety, it will invade adjacent structure slowly, 
and the forecast as to prolongation of life is more favorable. The 
prognosis, however, as to thorough eradication is markedly unfa- 
vorable. 

Treatment. — Statistics show that the radical operation gives a 
high mortality. Besides, should relief be given at the time, there 
is a marked tendency to recurrence. The treatment is, of necessity 
then, largely palliative. The patient's general health should be 
sustained by means of tonics. Arsenic, in the form of the arse- 
nous acid, pushed to its full physiological effect, seems to exert a 
favorable influence, but is not curative. Hemorrhage from ulcera- 
tion may be quite marked and necessitate the use of the galvano- 
cautery or styptics. 

Fauces, Pillars, and Soft Palate. — Sarcoma involving 
these structures is usually of the mixed-celled variety, and is con- 
sequently irregular in its growth. It is slow of development and 
tends to localize. If the neighboring tissue is involved, it is late 
and the involvement is slow. Owing to the double blood-supply 
and the lack of pressure, ulceration in these structures is not con- 
stant. The deeper structures are rarely, if ever, involved, and 
there is no external manifestation of the growth. 

Symptoms. — The symptoms are practically those of sarcoma 
of the nasopharynx, except that the pain is not so marked. There 
are very little ulceration and hemorrhage. Edema of the sur- 
rounding parts is often seen. 

Diagnosis. — The diagnosis can be established by microscopic 
examination associated with the clinical phenomena. In fact, this 
should be done in every growth, either malignant or benign. 

Prognosis. — The prognosis is fairly good. Statistics show 
recovery in 30 to 50 per cent, of the cases. However, there is a 
tendency to recurrence, either in the original site of the growth or 
in the adjacent structures. 

Treatment. — The treatment should consist in thorough and 
complete eradicatijn by means of curet, knife, or cautery, although 
this is rarely possible. Hemorrhage is likely to be severe, and 
may necessitate ligation of some of the larger vessels. 

Frequently, following an infection of the tonsils, there may be 
involvement of the glands of the neck, especially at the angle of 
the jaw and beneath the inferior maxillary bones. These en- 
larged glands resemble somewhat in appearance sarcomatous 
masses, but the history and the tendency to break down, also the 
temperature observed in such condition, will certainly establish the 
diagnosis. 

Pharynx. — Sarcoma of any variety occurring primarily in 
the pharynx is rare, but, when found, is seen in middle life, 
usually from thirtv-five to fifty. 



282 NEOPLASMS OF THE RESPIRATORY TRACT. 

Pathology. — The pathology of sarcoma in this location does 
not differ from that occurring elsewhere, except that it may 
assume the variety known as lymphosarcoma. This does not 
imply that sarcoma spreads by the lymphatics, as pathologists 
have taught us that sarcoma spreads by the blood-vessels, and 
carcinoma by the lymphatics. However, in this location, owing to 
the peculiar vascular supply, the lymph-spaces are simply invaded 
by the sarcomatous cells ; or, in other words, a lymphosarcoma is 
nothing more than lymphatic structure, invaded by the sarcom- 
atous cells in the same manner as any other connective tissue, as 
was pointed out by Ziegler. 

Symptoms. — The symptoms are those of mechanical obstruc- 
tion, together with the constant sensation of a foreign body in 
the pharynx. There is interference with deglutition, and, if the 
tumor reaches a considerable size, there will be some dyspnea, 
especially on lying down. Before ulceration occurs, there is hyper- 
secretion; after ulceration begins, the secretion becomes more 
tenacious, blood-stained, and of a disagreeable odor. The pain is 
not marked, except on irritation by pressure or by the involve- 
ment of adjacent structure. Hemorrhage may be marked, but, as 
a rule, is only slight. There is considerable interference with 
nasal respiration, and considerable alteration of voice. Edema 
and congestion of surrounding parts will occur. The cachexia 
which is present is due possibly rather to the inability of the 
patient to take food than to the presence of the growth. 

Diagnosis. — The diagnosis can best be determined by micro- 
scopic examination of a small portion of the growth. When ulcer- 
ation is present, the same precautions should be taken here as in 
any other ulcerating tissue — that is, it should be borne in mind 
that partially formed embryonic tissue at the base of an ulcer 
cannot be differentiated from sarcoma. 

Prognosis. — The prognosis depends somewhat on the variety ; 
but it is only a question of time when any form of the growth 
will result fatally. 

Treatment. — As sarcoma is sometimes surrounded by a pseudo- 
capsule, it may be possible in some cases to enucleate the tumor 
entirely ; but in the majority of cases the growth will have pene- 
trated this false capsule and invaded surrounding structure, and 
the enucleation, which at the time seemed to be complete, will be 
followed only by rapid recurrence. Palliative tracheotomy may 
have to be done if there is much dyspnea. If thorough eradica- 
tion cannot be accomplished through the mouth, a subhyoid pha- 
ryngotomy may be the last resort. If the lymphatic structure is 
extensively involved and the tumor so situated as not to permit of 
removal, eradication of the main growth will serve only to irritate. 
The ulceration, which is very disagreeable in this location, should 



SARCOMA. 283 

be frequently cleansed with hydrogen peroxid and cinnamon 
water, in equal parts. The pain and irritation produced by the 
raw surface can be considerably relieved by allowing the patient 
to chew pineapple, which has been cut up into small strips, or 
by using the prepared juice of the pineapple as a gargle or mouth- 
wash. 

Tonsil. — In my experience primary sarcoma of the tonsil is 
the most common of the malignant growths occurring in the ton- 
sil. It is usually of the lymphosarcomatous variety. It forms a 
distinctly prominent tumor, which projects into the fauces, inter- 
fering with nasal respiration, owing to obstruction of the naso- 
pharynx ; also, from its large size, causing difficult deglutition and 
interference with phonation. It is also, as a rule, highly vascular, 
tends to ulcerate, and is liable to severe and even fatal hemorrhage. 
Sarcoma of the tonsil tends to invade the deep structures. It may 
be of any variety, as to cell-formation. In the cases of rapid 
growth it is usually the small round cell, which is the most malig- 
nant variety, the size of the eel] not determining the malignancy, 
but the malignancy the size of the cell. Lymphosarcoma is 
nothing more than a mixed-cell sarcoma. 

Symptoms. — The symptoms produced by sarcoma of the tonsil 
are not peculiar to this growth, but similar symptoms may be found 
in other conditions. There is usually increased secretion, along with 
a peculiar fetid odor, especially after ulceration, which is almost 
characteristic and easily recognized by those frequently coming in 
contact with ulceration in these malignant growths. Often there 
is pain, which is of a peculiar character, increased on swallowing, 
and which is reflected to surrounding tissues — to the ear, to the 
angle of the jaw, and even to the tongue and teeth. Fortunately, 
the pain begins rather early in the tumor and soon directs atten- 
tion to the growth. With increase in size of the tumor, all the 
symptoms will be augmented. The difficulty in breathing and 
the impairment of the voice will become more marked as the size 
of the tumor increases. If the sarcoma should be of the large- 
celled variety or lymphosarcoma, the growth is not so rapid and 
the symptoms are less pronounced. Sarcoma of the tonsil is usually 
nodular and rather firm, but not hard, the consistency being often 
fluid or semi-fluid. The tumor contains very little fibrous tissue 
except as the lymphosarcoma, which will show fine trabecule of 
connective tissue. The blood-vessels have ill-formed walls, and in 
the small round-cell variety they are mere sluice-Avays, the walls 
being composed of the cells of the tumor, the vessels passing 
directly through the nests of cells. The tumor usually involves 
only one tonsil. 



284 NEOPLASMS OF THE RESPIRATORY TRACT. 

Diagnosis. — 

Sarcoma of the Tonsil. Carcinoma of the Tonsil. 

At almost any age ; usually over Does not occur early in life ; usually 

fifteen. over forty. (Cases have been reported 

at thirty years of age. ) 

Often primary. Barely ever primary. 

Highly vascular ; ulcerates early. Ulcerates late ; very little hemor- 

rhage. 

Cervical glands not involved except Cervical glands involved early, 

late. 

May be encapsulated. Not encapsulated. 

Difference not noted. More common in males than females. 

Prognosis. — The prognosis for sarcomata of the tonsil is bad, 
as they are apt to recur. 

Treatment. — Prompt surgical interference should be instituted ; 
and, if the malignancy of the growth be early recognized, its com- 
plete eradication may be effected through the mouth, or from the 
outside by an incision in the neck. 

Removal through the Mouth. — This may be accomplished by 
means of the thermocautery or the galvanocautery. In the ear]y 
stage the tumor is usually encapsulated, and may be dissected out 
by means of a scalpel and dry dissector. The entire mass may 
in some cases be removed by the ordinary tonsillotome. 

Removal by Incision through the Neck. — This consists in an 
incision extending from along the anterior border of the sterno- 
mastoid muscle, beginning on a line with the base of the ear, 
and extending to below the level of the tumor. This will 
necessitate an incision of from 2^- to 4 inches in length. A second 
incision extends along the lower portion of the inferior maxilla 
and joins the first incision. The tissues can be carefully dissected 
down until the tumor is reached and removed. Czerny's method 
consists in an external incision which extends from the angle of 
the mouth to the anterior border of the masseter muscle, and 
thence downward to the level of the hyoid bone. This operation 
necessitates a preliminary tracheotomy. 

I/arynx. — Some confusion in the classification of malignant 
growths of the larynx is due to the fact that the word malignant 
has been used to designate both sarcoma and carcinoma in their 
different varieties — indeed, the words sarcoma and carcinoma have 
been used as almost synonymous ; but the fact that sarcoma is an 
embryonic connective-tissue growth and carcinoma is an embryonic 
epithelial-tissue growth has enabled a differentiation to be made 
between the two malignant growths, and has cleared up the 
confusion. 

Sarcoma of the larynx may occur at any age, though not usu- 
ally in the very young. The earliest authenticated case reported 
was at the age of nineteen. There seems to be no definite eti- 



SARCOMA. 285 

ological factor predisposing or exciting. The histology of the 
tumor is the same as when found elsewhere, and the growth is con- 
trolled by the same law that applies to all varieties of sarcoma — the 
larger the cell the slower the growth ; the smaller the cell the more 
rapid the growth. The tumor has its origin in the deeper struct- 
ures, and, while the growth may be nodular, it presents a smooth 
surface. Although finally involving any portion of the larynx, it 
is usually located primarily in the vocal cords, and implicates the 
ventricle and ventricular bands, and, occasionally, the epiglottis. 
It is usually confined to the structures of the larynx, although 
this failure to extend is true of sarcoma in any location that is 
backed up by bony or cartilaginous walls. The growth may 
involve the entire larynx, or it may be unilateral, anterior or 
posterior. 

Symptoms. — There is early impairment of the voice in addi- 
tion to interference with respiration, which rapidly grows worse 
with the growth of the tumor. There is an irritating, spasmodic, 
hacking cough. Before ulceration there is very little change in 
the secretion. The apparent increase is due to the accumulation 
of the normal secretion in the mouth, ow r ing to the fact that swal- 
lowing causes pain. After ulceration begins, the cough increases, 
the secretion becomes of a more mucopurulent character, is more 
tenacious, and offensive in character. Ulceration occurs early, and 
there is usually considerable hemorrhage, which, however, is more 
continuous than it is profuse, and is usually not alarming. Sar- 
coma of the larynx does not, as a rule, attain considerable size, 
owing to the fact that its interference with respiration causes early 
recognition. AYhen the tumor is of the small round-cell variety, 
its growth is very rapid. In sarcoma of the larynx the adjacent 
structure is rarely, if ever, involved ; but, if occurring in the 
adjacent structure, the larynx may be involved secondarily. 
The cachexia which is present in some cases is not due to the 
tumor so much as it is to the interference with respiration and 
deglutition. The pain is irregular and intermittent, and, while at 
times it may be severe, is usually rather a feeling of discomfort 
than actual pain. 

Diagnosis. — A positive diagnosis of sarcoma of the larynx 
is difficult to make. However, much can be done toward a def- 
inite diagnosis by reinforcing the clinical history by a microscopic 
examination of a portion of the growth. The obtaining of a 
specimen from a tumor of this kind is by no means an easy task, 
and the irritation produced makes it questionable whether the 
procedure is warranted ; besides, the nature of the growth, whether 
malignant or benign, sarcoma or carcinoma, demands surgical 
interference. 

The prognosis is fatal. 

Treatment. — Any surgical interference, except complete resec- 



286 NEOPLASMS OF THE RESPIRATORY TRACT. 

tion or extirpation of the larynx, serves only as a palliative meas- 
ure. The form of operation will depend entirely on the size of 
the growth and the extent of involvement. In most cases, pre- 
liminary tracheotomy is necessitated. 

MIXED TUMORS. 

Adenocarcinoma. — The tumor described under this heading 
is, in reality, nothing more than a tubulated epithelioma — which 
is a carcinoma having its origin in gland-structures — where the 
proliferated epithelial cells from the lining acini or tubules invade 
the surrounding tissues. The adenocarcinoma is a rare growth, 
and few cases have been reported. The adenomata, containing 
quantities of embryonic epithelial type of tissue, would be a 
suitable site for carcinomatous growth. In fact the gland tumors 
are always suspicious and may frequently be the site of a carci- 
nomatous or malignant growth. 

Myxocarcinoma. — The so-called myxocarcinoma is, from a 
pathological standpoint, really not a separate variety of carcinoma. 
It is a mucoid or myxomatous degeneration occurring in any 
variety of carcinoma. Myxocarcinoma bears the same relation 
to carcinoma that the term melanotic does to sarcoma, merely 
expressing the variety of change. 

Teratoma. — This is a mixed tumor containing hypoblastic, 
epiblastic, and mesoblastic structure. It is really a congenital 
tumor. Under this variety we have the dermoid growth, which 
is more properly considered under cysts. 

Glioma of the Nose. — Glioma, usually of a small size, con- 
sists of minute neuroglia, a small amount of connective tissue, and 
minute bloodvessels. When occurring within the nasal cavity 
they are usually of a small size. They occur in the very young 
and are non malignant. 

Telangiectoma. — This tumor may involve the mucous mem- 
brane of the nose, of the mouth, and especially at the junction of 
the skin and mucous membrane. While the tumor rarely assumes 
any great size, yet its location makes it a source of great annoy- 
ance and disfigurement. One of the most striking characteristics 
of this condition is that it is likely to affect more than one mem- 
ber of a family. Two cases reported by Osier were brothers ; two 
reported by Chiari were sisters, and A. Brown Kelly reports two 
cases which were sisters. In Osier's two cases he found that fre- 
quently epistaxis had occurred in five other members of the fam- 
ily. Epistaxis is one of the early manifestations of the disease, if 
it involves the nose. There is a tendency to bleed, no matter 
what the location of the tumor. The bleeding will take place in- 
definitely, and the amount of blood lost varies greatly. There are 
few associated symptoms. In the larger telangiectases painful ten- 
sion is sometimes felt. This is relieved if hemorrhage should occur. 



CYSTS. 287 

CYSTS. 

There seems to be considerable confusion in the classification 
of cysts, largely due to the different views as to the etiology and 
pathology of the various forms. Again, the distinction does not 
seem to be made universally between cystic degeneration and a 
true cyst. 

By a simple or retention-cyst is meant that by some inflamma- 
tory process, either within the duct of the gland or in the surround- 
ing structure causing pressure on the duct, its lumen is gradually 
obstructed. This gradual obstruction, interfering with the outflow 
of secretion, slowly produces a saccular dilatation within the duct. 
With complete occlusion and by continued secretion the cyst 
increases in size. Owing to distention and pressure, the epithelial 
cells lining the obstructed duct will atrophy and be followed by 
degeneration and desquamation. By its own weight it drags down 
the loose structure and gradually becomes more pedunculated. 
This pressure and distention cause thinning of the wall of the 
cyst. Retention-cyst usually occurs after twenty years of age, 
more commonly in middle life or in the aged. 

Cystoma has been used by many writers as a general term 
applied to any variety of cyst, but such pathologists as Hamilton, 
Ziegler, Cornil, and Ranvier use the term as applying to congen- 
ital cyst-formation, or to a cystic dilatation not necessarily con- 
genital occurring within the lymphatics. 

Dermoid cysts develop either from inclusion of a portion of the 
epiblastic layer within the mesoblast, or from the distention of the 
cavity of some persistent fetal structure which in the normal proc- 
ess of development should have been obliterated. The cyst-wall 
contains hair-follicles and sebaceous glands, while the contents of 
the cyst are formed by the secretions from the sebaceous glands 
within the wall. Although they may occur in almost any part of 
the body, the common site is at a point in the embryo where 
fissures exist, permitting of possible inclusion of a portion of the 
epiblastic layer of the blastoderm. This would be especially true 
about the face and head, where such fissures occur. 

Simple or Retention-cysts (Mucocele). — This variety of 
cyst is common in the nose and nasopharynx and in the upper 
portion of the larynx. In the nasopharynx it has its origin in 
the adenoid structure of the vault. They are rarely ever multiple, 
and the symptoms produced are identical with those of myxoma. 
One case seen by the author showed a single cyst of the anterior 
pillar, just above the faucial tonsil. 

The treatment should consist in puncture, followed by curet- 
ment, to insure the complete removal of the sac. When pedun- 
culated, they may be removed by means of the cold-wire snare 
(Fig. 91). 



288 NEOPLASMS OF THE RESPIRATORY TRACT. 



Fig. 91.-Dench's nasal polypus-snare. 

Cystoma (Hygroma, Hydroma). — The cystoma, which 
may be found in the nose, nasopharynx, pharynx, or larynx, is a 
cystic dilatation of the lymph-vessels normally present. It may 
occur at any age, although more commonly found after twenty- 
five. This is a variety of cyst that tends to recur, which is largely 
due to the fact that its location may be such as not to permit of its 
complete removal. 

Dermoid Cysts. — Dermoid cysts are rarely found in any 
part of the respiratory tract other than the nose, and when located 
in this organ they are usually situated at the inner angle of the 
orbit and involve the eye as well as the nose. If from their pres- 
ence they interfere with nasal respiration, they should be removed 
by excision. 

Blood cysts of the septum have been described by some 
writers. The cystic condition of the middle turbinal has been 
described on page 110. A number of cases have been reported in 
which cysts have formed on the floor of the nose and resemble 
very much in appearance a polypoid mass. The etiology of these 
cysts is very obscure. The histological structure of the wall of 
the cyst does not differ from cysts found elsewhere. 



CHAPTER XII. 
DISEASES OF THE ANTERIOR NASAL CAVITIES. 

Septum. 

1. Malformations. 

2. Deformities. 

a. Deviation or Deflection. 

1. Disease. 

2. Traumatic. 

3. Congenital. 

b. Synechia. 

1. Congenital. 

2. Acquired. 

3. Collapse of N asal Alee. 

4. Ulceration and Perforation (Caries and Necrosis). 

5. Edema (Submucous Infiltration). 

6. Abscess. 

a. Acute. 

b. Chronic. 

7. Correction of External Nasal Deformities. 

8. Syphilis. 

9. Tumors. 

a. Exostoses, Ecchondroses, Spurs, etc. (See Tumors, page 245.) 

b. Blood-cyst or Hematoma. 

SEPTUM. 

The septum of the nose is composed of cartilage and bone. 
The posterior bony part is formed by the vomer. The anterior or 
cartilaginous portion, known as the cartilage of the septum, is some- 
what quadrilateral in form, thicker at its margin than in the cen- 
ter, and completes the separation between the nasal fossae in front. 
Its anterior margin, thickest above, is connected from above down- 
ward with the nasal bones, with the front part of the two upper 
lateral cartilages, and with the inner portion of the two lower 
lateral cartilages. Its posterior margin is connected with the per- 
pendicular lamella of the ethmoid ; its inferior margin with the 
vomer and the palate processes of the superior maxillary bones 
(Fig. 3). 

The cartilages and bones are united by tough fibrous mem- 
branes — the perichondrium. The mucous membrane lining the 
interior of the nose is continuous with the skin externally. 

The cartilaginous framework consists of five pieces — the two 
upper and two lower lateral cartilages, and the cartilage of the 
septum (Figs. 3, 4). 

The upper lateral cartilages are situated below the free margin 
of the nasal bones ; each is flattened and triangular in shape. Its 

19 289 



290 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

anterior margin is thicker than the posterior, and is connected with 
the fibrocartilage of the septum. Its posterior margin is attached 
to the nasal process of the superior maxillary and nasal bones. 
Its inferior margin is connected by fibrous tissue with the lower 
lateral cartilage ; one surface is turned outward, the other inward 
toward the nasal cavity. 

The lower lateral cartilages are two thin flexible plates, situated 
immediately below the preceding, and bent upon themselves in 
such a manner as to form the inner and outer walls of each orifice 
of the nostril. The portion which forms the inner wall, thicker 
than the rest, is loosely connected with the corresponding part of 
the opposite cartilage, and forms a small part of the columna. Its 
outer extremity, free, rounded and projecting, forms, with the 
thickened integument and subjacent tissue, the lobe of the nose. 
The part that forms the outer wall is curved to correspond with 
the ala of the. nose ; it is oval and flattened, narrow behind, where 
it is connected with the nasal process of the superior maxilla by a 
tough fibrous membrane, in which are found three or four small 
cartilaginous plates (Fig. 4) (sesamoid cartilages) — cartilagines 
minores. Above, it is connected to the upper lateral cartilage and 
to the front part of the cartilage of the septum ; below, it is sepa- 
rated from the margin of the nostril by dense cellular tissue ; 
and in front it forms, with its fellow, the prominence of the tip 
of the nose. 

The arteries of the nose are the lateralis nasi from the facial 
and the nasal artery of the septum from the superior coronary, 
which supplies the alse and septum, the sides and dorsum being 
nourished by the nasal branches of the ophthalmic and infra-orbital. 

The veins of the nose terminate in the facial and ophthalmic. 

The nerve-supply is derived from the facial, infra-orbital, 
infratrochlear, and a filament from the nasal branch of the 
ophthalmic. 

The conditions causing nasal obstruction have been admirably 
arranged by Walsham, and the following table is as arranged by 
him, with some slight modifications and additions. 

Tabulae View of Conditions Causing Nasal Obsteuction. 

a. inteanasal. 

I. Local. — a. Septal. — 1. Spur and erection of tubercle. 2. 
Deviation and deflection, or split septum (Fig. 92). 3. Disloca- 
tion of columnar cartilage. 4. Hematoma. 5. Enchondroma 
and osteoma. 6. Papilloma. 7. Vascular and erectile tumors. 
8. Myxoma (polypus). 9. Sarcoma and carcinoma. 10. Inflam- 
mation and abscess. .11. Necrosis. 12. Local contagious ulcers 
(soft chancre). 13. Primary syphilitic sore (hard chancre). 14. 
Gumma and periostitis. 15. Tubercle. 16. Lupus. 17. Rhino- 
scleroma. 18. Glanders. 19. Actinomycosis. 



SEPTUM. 291 

b. Turbinal. — 1. Erection of turgescence. 2. Hypertrophy 
(local and general). 3. Necrosis. 4. Yarix. 5. Vascular and 
erectile tumors. 6. Myxoma (polypus). 7. Papilloma. 8. Sar- 
coma and carcinoma. 9. Tubercle. 10. Gumma. 11. Lupus. 
12. Khinoscleroma. 13. Actinomycosis. 

c. Accidental. — 1. Foreign body. 2. Rhinolith. 3. Adhesion 
of turbinal to septum. 4. Larvae, maggots, etc. 

II. General. — 1. So-called hypertrophic rhinitis. 2. Syph- 
ilis. 3. Tubercle. 4. Lupus. 5. Khinoscleroma. 6. Actino- 
mycosis. 7. Glanders. 8. Diphtheria. 9. Congenital smallness. 

B. EXTRAXASAL. 

I. Occlusion of Anterior Nares. — 1. Congenital malforma- 
tion. 2. Cicatricial contraction, due to — (a) Injury and burns ; 
(6) syphilis ; (c) tubercle ; (d ) lupus. 

II. Occlusion of Posterior Nares. — 1. Congenital malfor- 
mation. 2. Cicatricial contraction, due to — (a) Syphilis ; (b) 
tubercle ; (c) lupus. 

III. Obstruction in the Nasopharynx. — 1. Adenoid vegeta- 
tions (hypertrophy of pharyngeal tonsil). 2. Growth from the 
vault (nasopharyngeal polypus). 3. Retropharyngeal abscess. 4. 
Adhesion of soft palate to pharyngeal wall. 5. Retropharyngeal 
adenoma. 6. Retropharyngeal sarcoma. 7. Enlargement of the 
tonsils (adenoma). 8. Tumors of the soft palate. 9. Meningocele 
and encephalocele. 10. Growth from sphenoidal sinuses. 11. 
Enchondroma of Eustachian tube. 

IV. Obstruction due to Extension of Growths from 
Neighboring Cavities. — 1. Fibrous, osseous, sarcomatous, and 
carcinomatous tumors of the antrum. 2. Growths from the 
ethmoidal, sphenoidal, and frontal sinuses and fluid distention. 

Symptoms, Signs, and Effects of Nasal Obstruction. 
— The chief symptoms of nasal obstruction are : (a) Inability to 
breathe freely through the nose ; (b) an alteration in the voice ; 
(c) a characteristic facial expression; and (d) the presence of a 
discharge from the nose, or at the back of the throat. 

1. Swelling or redness of the external nose. 2. Intolerable 
itching in the nostril. 3. Headache. 4. Vertigo. 5. Aprosexia. 
6. Impaired general health. 7. Defective development. 8. De- 
formity of the chest. 9. Hypochondriasis and melancholia. 10. 
Shallow breathing. 11. Elongation of the uvula. 12. Spas- 
modic cough and asthma. 13. Aphonia. 14. ^sight-sweats. 15. 
Nightmare and distressing dreams. 16. Snoring. 17. Constant 
and oft-recurring catarrh of the pharynx, larynx, trachea, and 
bronchi. 18. Restlessness, twitching, and even convulsions in 
young patients. 19. Sneezing. 20. Perversion of the senses of 
smell and taste. 21 . Sensation as of a movable bodv in the nose. 



292 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

22. Deafness. 23. Salivation. 24. Eye-affections. 25. Hernia. 
26. Stammering and stuttering, nocturnal enuresis, epilepsy, 
chorea, dyspepsia, gastralgia, palpitation of the heart, and mus- 
cular rheumatism. 

The causes of nasal obstruction may be conveniently classi- 
fied under the following heads : 

1. The intranasal, or those depending on some primary condi- 
tion in the nose itself. 

2. The extranasal, or those depending on some condition exter- 
nal to the nose. 

The intranasal may be subdivided into the local and the 
general. 

(1) The local causes are due to lesions limited to the septum, 
turbinals, or other parts of the nasal chambers ; to accidental 
conditions, as the presence of a foreign body or rhinolith ; and to 
adhesions between the turbinals and septum. 

(2) The general intranasal causes are such as depend on a gen- 
eral swelling of the mucous membrane, due to catarrh or to such 
affections as syphilis, tuberculosis, rhinoscleroma, etc. 

The extranasal causes may be subdivided into the following 
classes : 

(1) Occlusion of the anterior nares, due to congenital malfor- 
mation, or cicatricial contraction following an injury or such dis- 
eases as syphilis or lupus. 

(2) Occlusion of the posterior nares, which may also be the 
result of congenital malformation or of cicatricial contraction. 

(3) Obstruction in the nasopharynx, due to adenoid vegeta- 
tions ; polypi, or growths ; enlargement of the faucial tonsils ; 
adhesion of the palate to the postpharyngeal wall ; tumors of 
the soft palate ; meningocele and encephalocele. 

(4) Obstruction caused by extension of growths from neigh- 
boring cavities, such as the antrum or the ethmoidal or frontal 
sinuses. 

i. MALFORMATIONS OF THE SEPTUM. 

By malformation of the septum is meant any congenital con- 
dition in which there is an abnormal formation of the cartilaginous 
or bony septum due to developmental causes. It is true that 
malformation may cause deflection, deviation, or deformity of the 
septum. Malformations are usually limited to the cartilaginous 
septum, there being only a partial development of that cartilage. 
From this defect there may be a communication from one nostril 
to the other, in which, while it resembles a perforation, there is 
no loss of structure — simply a failure of development. The car- 
tilage may be deficient in any of its dimensions. Congenital mal- 
formation may also be found in the perpendicular plate of the 
ethmoid, as well as in the vomer, in which there may be only 



DEFORMITIES OF THE SEPTUM. 



293 



partial development. The congenital defects of the nasal septum 
are usually associated with other irregular development of the 
bones of the floor of the nose — in fact, many of the facial bones 
may be involved in the congenital deformity. 



2. DEFORMITIES OF THE SEPTUM. 

In a perfectly formed nostril the septum should be perpendicu- 
lar to the floor of the nose, separating the two cavities into cham- 
bers of equal dimensions (Fig. 2). As a rule, however, there is a 




Fig. 92.— Various deflections of the septum : 1, Deflection into right nostril ; no redun- 
dant tissue ; 2, letter S deflection ; 3, redundant tissue at floor ; 1, redundant tissue or spur; 
5, redundant tissue, concave ; 6. redundant tissue, angular curvature ; 7, split cartilaginous 
septum ; 8, deflection with overlapping, with groove on opposite side ; 9, 10, and 11, meth- 
ods of correction ; 12, shows thickened septum with redundant tissue perpendicularly and 
anteroposteriorly ; 13, shows redundant tissue which can he eliminated by the removal of 
the curved portion ; 11, shows lateral view of deflected septum in which there is redun- 
dant tissue anteroposteriorly and perpendicularly. 

slight difference in the size of the two nostrils, the septum fre- 
quently deflecting slightly to one side. This may become more 



294 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

pronounced in adult life, owing to irregular change within the 
cartilaginous structure. The tendency to deviation is also increased 
by inflammatory processes. It is almost impossible to describe 
the various deviations or deflections of the septum, as each indi- 
vidual case will present slightly different features. The curvature 
in the septum may be either longitudinal or perpendicular. It 
may be a single curvature,, as shown in Fig. 92, 1, or it may be of 
the letter S or scroll-shaped variety, as shown in Fig. 92, 2. It 
may be limited to the cartilaginous portion or may involve both 
cartilage and bone, rarely ever involving the bony septum alone. 
Fig. 92, shows some of the various deflections with and without 
redundancy. 

1. Deviation or Deflection from Disease. — Deflection 
of the septum may be brought about by disease occurring directly 
in the structure, or as a secondary condition depending entirely 
upon some constitutional lesion. Inflammatory processes involv- 
ing the mucous membranes lining the cartilage may so weaken it 
as to permit of slight deflection. This is especially true in puru- 
lent rhinitis in children, also in the strumous and the rachitic 
diatheses. Atrophic rhinitis has been granted by some authors as 
a possible cause of deflection. It is possible that in the early stage 
of the inflammatory process the cartilage, owing to its inflamed 
condition, and possibly to its irregular, uneven development from 
muscular action of the external nasal muscle, may be slightly 
deflected. However, I think, as a rule, the deflection existed 
before the atrophic rhinitis, and was rather an exciting factor than 
a result of that process. Deviations may also follow, in childhood, 
upon diseases of the teeth, especially during first dentition ; and, if 
early recognized, many cases might be prevented. Superficial 
ulceration in syphilis, tuberculosis, and lupus, without actual per- 
foration, may cause deflection and deformity. Simple ulceration, 
as well as ulceration following diphtheria and typhoid fever, are 
also exciting factors in deflection. Perichondritis, whether asso- 
ciated with any specific inflammation or not, may result in deflec- 
tion. Enlarged turbinated bones, by pressure on the septum, with 
the resulting inflammatory changes, will produce deflection ; the 
same can be said of tumors. In uric-acid diathesis there is pro- 
nounced irritation of the mucous membrane, which may result in 
perichondritis and tend toward deflection. Deviation due to sim- 
ple abscess of the septum presents a very small scar on the surface, 
while that due to a specific process will present considerable scar- 
tissue. Perichondritis, regardless of the cause, may result in the 
destruction of a portion of the cartilage, leaving the soft parts 
intact ; yet sufficient of the cartilage is destroyed to give marked 
deviation and deformity. 

2. Traumatic Deflection.— Deviation of the septum from 
injury occurs most frequently in childhood, although it may not 



DEFORMITIES OF THE SEPTUM. 295 

be recognized until adult life. Children are subjected more often 
to injury of the nose, and at the time little attention may be given 
to the injury, which may later result in a serious deflection. Owing 
to the flexibility of the cartilaginous septum, blows of sufficient force 
to cause deflection of this structure must necessarily involve the 
bony septum. Great difficulty may be experienced in determining 
the cause of the deflection ; yet frequently, when the patient is con- 
scious of the obstruction or irregularity of his nostril, he will state 
that it followed a severe blow on the nose. Such an injury may 
occur in a child that is not of sufficient age to recognize the impor- 
tance of nasal breathing. Through fear of treatment it may say 
nothing about the injury, although the deflection or the thickening 
produced by the callus thrown out after the fracture of the bone 
or cartilage may almost obstruct nasal breathing on one or both, 
sides. In any variety of deflection the deformity may be purely 
internal, although in deflections due to blows it is usually notice- 
able externally. The direction of the blow and its force determine 
the degree and variety of deflection. A peculiar case, illustrating 
the effect of a blow on the nose, I observed in my private 
practice. 

A young man twenty-two years of age, while playing football, 
received a severe blow directly on the nose by colliding with the 
head of an opposing player. The injury was followed by consider- 
able external swelling, but in the course of a few days all external 
inflammatory symptoms had disappeared. However, the obstruc- 
tion to the nasal breathing continued, although after some two or 
three weeks, when the internal swelling had entirely subsided, 
there was considerable improvement in this as well. When exam- 
ined some three months afterward, practically no external deform- 
ity was noticed, there being no change in the facial contour. 
Rhinoscopic examination, however, revealed the cartilaginous sep- 
tum bulging into each nostril, occupying at least two-thirds of 
each nasal space. By pressure within each nostril the cartilage 
could be pushed back to the median line. The force of the blow 
had simply separated or split the cartilaginous septum (Fig. 92, 7). 
This was crushed sufficiently to permit of its being easily held in 
position and sufficient irritation set up to produce an inflamma- 
tory exudate between the two layers to allow union while held in 
position by the author's malleable tube, as shown in Fig. 93. 
Traumatic deflection and deformity may be of sufficient gravity 
to necessitate extensive surgical interference. This is especially 
true when the bony nasal framework is involved. 

A deflection of traumatic origin frequently occurs just within 
the nasal orifices. The irregularity of the cartilaginous septum 
itself being slight, the deflection is due entirely to a dislocation 
of the anterior end of the septum from the columnar cartilage. 
Owing to its location, the deflection is sufficient to cause obstruc- 



296 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

tion to nasal breathing. It shows as a prominence with a smooth 
covering of thin mucous membrane, which is usually slightly 
inflamed, owing to the mechanical irritation necessarily produced 
by its unnatural location. It is situated just within the anterior 
nares and extends to the mucocutaneous surface. There is a 
slight depression in the opposite nostril, corresponding to the 
prominence, which often can be seen without the aid of the nasal 
speculum. While this deflection is usually the result of injury, 
it is frequently met with as a consequence of disease or as a mal- 
formation in the sense of irregular development. The dislocation 
may produce deformity, the tip of the nose often drooping or 
deflecting slightly to one side. 

Slight dislocation occurs in a larger percentage of cases than is 
usually believed. The condition is rarely, if ever, of such grav- 
ity as to require surgical interference, unless it is associated with 
deformity of the cartilaginous or bony septum. If the cartilage 
is split, and the depression on the opposite side is slight, the ob- 
structing cartilage should be removed. This can be done without 
fear of the tip of the nose drooping, if the opposite side be intact. 
The mucous membrane should be dissected free from the carti- 
lage, the cartilage removed by gouge or knife (Fig. 48) ; the 
flap is then allowed to drop into position. Owing to the vas- 
cularity of the tissue, it will rapidly repair, and it is not necessary 
to stitch the membrane in position. The surface should be kept 
cleaned with warm boric-acid solution, 10 gr. to the ounce, and 
the nostril should be loosely packed with cotton saturated with 
hydrogen peroxid — for protection and not pressure. 

3. Congenital Deflection. — I believe that many cases of the 
so-called congenital deformity in the bones of the nose arc due to 
the fact that at birth during labor, owing to the position of the 
head in the birth-canal, considerable pressure has been exerted 
on the soft, almost cartilaginous, bones of the nose. It is a well- 
known fact that much can be done toward the shaping of the nose 
at this time. 

Again, that the free passage of air through the nostril has 
much to do with the regular development of the nasal fossa, as 
well as the formation of the superior arch and the asymmetry of 
the facial bones, I have frequently observed to be true. This is 
well illustrated in the irregular facial deformity, especially of the 
superior maxillary bones with irregular development of the teeth, 
which is seen when the nasopharynx is obstructed in early life by 
adenoid vegetations. The poor breathing through the nose allows 
the bones so to form as to produce the narrow slit-like orifice, and 
often the high V-shaped hard palate, so commonly found in mouth- 
breathers. 

Again, in the constant sniffling which is noticed in children 
with obstructed nasal breathing, a continual drawing down of 



DEFORMITIES OF THE SEPTUM. 297 

the facial muscles while the bony union is taking place will 
cause narrowing of the arch and give a peculiar dish-faced 
expression. 

I believe that the importance of the effect of perfect nasal 
respiration in early childhood on the regular formation and shape 
of the nasal cavities, thereby controlling the facial expression, 
cannot be overestimated. At least, observation shows that indi- 
viduals who in childhood have perfect respiration have a regularly 
formed upper jaw, regularly formed teeth, with perfect facial con- 
tour, while those with imperfect nasal respiration show exactly the 
opposite. I assert, then, that what is often termed malformation 
or congenital deformity is, in reality, developmental deformity, 
brought about by imperfect nasal respiration, or imperfect and 
irregular development due to systemic malnutrition or dyscrasia. 
The worst feature of these developmental deformities is, that unless 
perfect nasal respiration is established early in life — i. e., before the 
fifth or sixth year, or not later than the seventh — the bony and 
cartilaginous framework becomes so firm that little can be done 
toward increasing the nasal space for breathing, and the individual 
will of necessity be a mouth-breather for life. 

Treatment. — Of the many operations suggested for the correc- 
tion of septal deflection, much discussion and confusion has been 
caused by the fact that the author of a method suggested it for a 
particular variety of deflection ; then some operator, having his 
attention called to this particular method, applies it to some other 
variety of deflection, the result being unsatisfactory, and hence he 
condemns the method. There are many methods of operation for 
the same variety of deflection, no doubt some better than others, 
but my own experience has been that if any method for any par- 
ticular deflection is carried out according to the details given 
bv the originator, and, as I have said before, applied to the 
proper deflection, satisfactory results can usually be obtained. In 
many instances the method is not wrong, but the operator has ap- 
plied the method to the wrong variety of deflection. 

Modernization, rather than abandonment of the older methods, 
is what is needed. Since Adams' description of his original opera- 
tion many so-called new methods have been published, and the 
originators, equally sincere, have pointed out why their particular 
method is the best, ignoring the fact that each must be based on 
the same mechanical law. The fact that we have so many opera- 
tions for the correction of septal deformities, differing as the case 
may be in some point of more or less importance, is an indication 
of another fact, viz., that there are also manifold variations in the 
character of septal irregularities, so that no one method can be 
closely adhered to in the correction of all deflections. 

So far as the major principles are concerned in every deflection, 
whether it involves the cartilaginous or bony septum, or both, 



298 DISEASES OF THE ANTEBLOB NASAL CAVITIES. 

there are two constant facts or features : (1) There are two fixed 
points, no matter what the direction or the angle of deflection , and (2) 
there is redundant tissue either perpendicularly or horizontally 
between these fixed points. 

The object, then, to be attained in every case is to place or re- 
store the septum to the median line, having on each side as nearly 
a plain surface as possible, thus equalizing the size of the two 
nostrils and establishing free nasal breathing, and at the same time 
leaving the straightened septum covered with functionating 
mucous membrane. This will evidently necessitate the removal 
of, or the displacement and overlapping of, certain tissues, a pro- 
cedure which every one experienced in nasal surgery knows can- 
not be accomplished in every case by any one method. That 
the various varieties of deflection will necessitate modifications of 
every known operation is also apparent, and each individual case 
must therefore determine which method will be the most available. 
Too frequently operators, particularly those inexperienced, are prone 
to follow methods and to be led away by some particular fad with- 
out stopping to reason out the subject for themselves. When the 
orthopedic surgeon attempts to correct a bow-leg he makes a mathe- 
matical calculation of the amount of bone tissue it is necessary to re- 
move from the convex side so as to place the bone, when he makes 
the green-stick fracture, in the median or perpendicular line. Why, 
then, should not the nasal surgeon, in correcting a deflection of the 
cartilaginous or bony septum, apply the same principle ? Why, 
because a cartilaginous or bony septum is deflected, dissect out and 
remove the entire supporting structure ? Frequently the only explan- 
ation offered is that the deflection will never recur. This is quite 
true, but the orthopedic surgeon certainly would not remove the 
entire bone lest there should be a further tendency to bow-leg. 
In the past few years there has been a great deal of journalistic 
literature on the subject of submucous resection, a method of 
merit in certain cases, yet one which, after many septa have 
been sacrificed, will settle itself again to a state of reasonable- 
ness, and, like other methods, be employed where it conforms to 
rational indications. Rare indeed, however, will the even moder- 
ately conservative surgeon, governed not by fad, but by the prin- 
ciple of fitness, find in his cases of septal deflection occasion to 
remove the entire cartilage and bone. In some it is necessary to 
remove only a small portion of redundant tissue, so that the sep- 
tum may be swung into the median line ; while in others of more 
marked deflection the overgrowth of tissue will necessitate more 
extensive removal. The submucous resection, then, of a portion 
of the septum, bony or cartilaginous, is only justified when it 
is necessary to correct the deformity and allow the septum to 
swing into the median line, and just sufficient to allow this. 



DEFORMITIES OF THE SEPTUM. 299 

From the amount of literature on the subject one would sus- 
pect that this was a new subject, when in reality it is not a 
new method in any sense. To be sure there are some modi- 
fications and a multiplicity of instruments, but the principle sug- 
gested and involved in the suggestion of E. Fletcher Ingals, of 
Chicago, almost twenty years ago, and by Hartmann, Roux, 
Juracz, and Krieg about the same time, is the underlying one of 
the submucous resection. 

Chatelier, of Paris, described in 1890 in his lectures the opera- 
tion which, to all intents and purposes, is the submucous resection 
which is so much in vogue at present. He made a straight in- 
cision near the mucocutaneous junction, through which he at- 
tempted to remove the deformed septum without perforating the 
mucoperiosteum of the opposite side. 

The alphabetical operations are becoming numerous. The T, 
the V, the U, the L, and the H are already well-known methods. 

There is a variety of deflection involving only the cartilagi- 
nous portion, which is very thin and flexible. By inserting the 
finger into the nostril the septum may be straightened back to the 
perpendicular. In such cases, it is not necessary to lacerate the 
tissue by holding it in position with pins or by cutting to weaken it, 
so that it may be held more readily in position. The plan which I 
have found very successful — merely a modification of the pressure- 
method suggested by Quelmalz — is the use of a flexible or, rather, 
malleable tube, which is shaped first to fit the deflection, then, by 
gradually widening the tube, there is gradual pressure brought to 
bear on the deflected part, producing a slow inflammatory proc- 
ess. The tubes, as shown in Fig. 93, are inexpensive, and should 
be made to suit each case. The caliber of the tube is increased 




Fig. 93.— Author's malleable nasal tube. 

or diminished to suit the amount of pressure required. The. tube 
being of soft metal, the length can also be regulated to suit 
individual cases. With the blade of an ordinary pocketknife 
you can cut the tube to any size desired. Another advantage of 
this malleable tube is that after the operation, on account of the 
inflammatory swelling, the pressure may become too great, and 
the size of the tube can then be reduced by lessening its cal- 
ibre with a pair of ordinary thumb-forceps. After the swelling 
goes down, if much support is needed, the tube can be dilated 



300 DISEASES OF THE ANTERIOR NASAL CAVITIES, 

again to give sufficient support. As a rale, it will necessitate the 
wearing of the tube from four to twelve hours each day for 
two or three weeks, although frequently it can be left out as long 
as three or four days at a time. The tube should never be allowed 
to remain in the nostril sufficiently long to produce ulceration, but 
if the directions given above are followed, as to the length of 
time it should remain in position, ulceration will not occur. This 
gradual pressure will, from inflammatory organization, thicken the 
septum, increasing its strength. 

Deflection of the septum does not always demand surgical 
interference. While any irregularity in size or unevenness of the 
contour will tend to promote catarrhal conditions, yet if there is 
sufficient space for the free passage of air, operative interference 
is not demanded. Another variety of cases in which surgical in- 
terference will give no relief is those in which the septum may 
be slightly deflected, yet the nostril is extremely narrow poste- 
riorly ; and while there is a slight difference in the two nostrils, the 
difference in size really does not amount to the thickness of the 
septum, so that while the moving over of the cartilaginous or 
bony septum would enlarge the one nostril, it would do it at the 
expense of the other. In the simple curvature, in which the septum 



Fig. 94.— Author's forceps for crushing the septum. The rounded surface of the forceps 
comes in contact with the tissue, thereby lessening the laceration. This is the reverse of 
other forceps. 

is thick and firm, I have found the following method to be most 
satisfactory : If the curve extends to the floor of the nostril or 
the junction of the cartilage with the superior maxilla, a cut should 
be made on the opposite side from the deflection, close to the base 



Fig. 95.— Roe's forceps. 



and extending through the mucous membrane to the cartilage. 
Then by means of the nasal saw (Fig. 53) the cartilage should 
be cut to about one-third its thickness. If, however, the cur- 



DEFORMITIES OF THE SEPTUM. 



301 



vature does not extend to the floor, this incision may be omitted. 
The patient should be anesthetized, and by the use of the for- 
ceps shown in Fig. 94, or the Roe forceps, Fig. 95, the carti- 
laginous septum is pressed into position by the forceps. The 
rounded blades prevent laceration of the tissue. This will per- 
mit of the moulding of the septum into the desired shape and 
position. It should then be retained in position by means 
of the tubes described in Fig. 93. If within the first twenty- 
four to forty-eight hours there are marked swelling and edema, 
the tube should not remain in position, as the parts can easily 
be moulded up to this time, since no inflammatory organiza- 
tion will take place under forty-eight hours. If, however, the 
swelling is not marked, the tube may be left in position from 
the first. The diameter can be controlled by the pressure and sup- 
port desired. The tube is for support, not pressure. While 
the tube is in position the nostril should be flushed every 
two to four hours, depending on the amount of secre- 
tion, with a tepid solution composed of boric acid, 10 grains ; 




Fig. 96.— Showing lateral deflection involving both bony and cartilaginous septum, with 
line for saw-cut to control the fracture in straightening. 

carbolic acid, 2 drops to the ounce of tepid water. Until the fifth 
or sixth day, should there be considerable swelling, causing marked 
pressure, the tube should be removed from the nostril daily, and 
allowed to remain out at least eight to ten hours ; this will prevent 
any likelihood of ulceration. Should this same curvature extend 
back to the bony framework, the same method should be employed, 
except that in order to control the line of fracture of the bony sep- 
tum, after cutting through the mucous membrane, the bone should 



302 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

be sawed, by means of the curved nasal saw shown in Fig. 53, to at 
least one-third its thickness. This should be done at two points, so 
as to divide the septum into equal thirds (Fig. 96). The line of 
fracture will thereby be controlled, as the septum is crushed by 
the rolling forceps. If the bony portion is thick and firm, the 
incision may have to be made deeper than one-third. If more 
force is required to correct the deformity than can be exerted by 
the rolling forceps, the dilating forceps (Fig. 97) should be used. 




Fig. 97— Sinexon's nasal dilator, the screw controlling the blade-separation. 

The septum should be retained in position in the same manner as 
described above. If the deflection is a vertical one of the triangle 
or V-shaped variety, before crushing, two vertical incisions should 
be made two-thirds of the entire perpendicular length, dividing 
the deflection into equal thirds. This can be done by means of 
the saw shown in Fig. 53. The straightening of the septum and 
its retention in position can be accomplished as described above. 
In nearly all cases of deflected septum the turbinate body, 
middle or inferior, on the concave side will always show en- 
largement. In some cases this is bony, but in the majority of 
instances enlargement is due to the physiological hypertrophy of 
the mucous membrane. This physiological hypertrophy is due to 
the fact that the mucous membrane in the wide-open nostril is per- 
forming more work than should be normally required of it ; 
hence the hypertrophy. When the septum is placed in the 
median line the originally obstructed nostril will be clear and 
open, while the originally open nostril will be somewhat obstructed, 
owing to the fact that the septum, being placed back in the median 
line, comes almost in direct contact with the hypertrophied tur- 
binal. 

It is a great mistake to remove this turbinate body before 
straightening the septum. By taking the work off and by allow- 
ing the originally closed nostril to resume its function, it will be 
found that in from one month to six weeks there will be beginning 
physiological atrophy of the hypertrophied mucous membrane of 
the originally wide-open nostril. 

My own experience has been that in at least 90 per cent, of the 
cases this membrane will return back to the normal and free 
breathing will be established in the nostril ; while, if the bone is 
removed before operation and this physiological atrophy occur, 
normal tissue has been sacrificed, and there is great danger of that 
nostril being too large and atrophic rhinitis follow. If, however, 



DEFORMITIES OF THE SEPTUM. 303 

there is enlargement of the bone and the tissue does not go back 
to the normal, giving it from three to six months' time, then such 
operative interference as the individual case indicates should be 
done ; but the enlarged turbinal should not be removed before 
straightening the septum. Wait until time determines the neces- 
sity of such an operation. 




Kyle's long nasal tube. 



The advantage of the tube seen in Fig. 93 is that it can be 
moulded to fit any nostril, and the pressure can be controlled. 
The metal is soft, so as to allow its being cut very easily with an 




Fig. 99.— Showing Kyle's long nasal tube in position. 

ordinary knife, in order that the tube may be shortened at will 
and adapted to individual cases ; besides, the surface impinging 
against the septum is flat, thereby distributing and equalizing the 
pressure, with less likelihood of ulceration. The tube can be 
indented to fit any projecting point on the septum, lessening 
danger of ulceration from pressure. The outer surface may be 
also rounded and moulded to fit the turbinal surfaces, so as not to 
permit of excessive pressure on any one point. 




304 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

For the last two years I have been using a much longer tube 
than the one shown in Fig. 93. The tube (Fig. 98) extends along 
the floor of the nose and into the nasopharynx as shown in Fig. 
88, the advantage of this being that the secretions will not accumu- 
late around the end of the tube, and if there is any swelling in the 
mucous membrane it will not bulge over and close up the end of 
the tube. It must be remembered that the tube used after opera- 
tion in these cases is for support only, and not pressure, and the 
advantage of this malleable tube is that if on account of swelling 
too much pressure is exerted, the diameter of the tube can be less- 
ened by compression. The dotted line indicates the larger tube. 
Another variety of deflection of the septum occurs, in which 
there seems to have been splitting of the two 
halves, with bulging on only one side (Fig. 
100), the opposite side being almost perpen- 
dicular. The deflected portion assumes an 
acute angle, the apex of which is markedly 
thickened. In such deflections, all that is 
necessary is that a semicircular incision be 
made from the under portion of the projection, 
the mucous membrane dissected up, and the 

Fig. 100.— Septum with j i • x*i • i • j^- 

bulging on one side only, underlying cartilaginous or bony projection 

sawed off. Great care should be taken not 
to penetrate the septum or injure the mucous membrane or blood- 
supply of the opposite side, thereby lessening the danger of ulcera- 
tion or perforation. 

In operations for the correction of the various deflections of the 
nasal septum it has been my experience that the greatest difficulty 
to overcome was not that of placing the septum in the median 
line, but in removing sufficient tissue to prevent any backward 
pressure on the septum and a consequent return of the deflection. 
While no one method is applicable in all cases, I have found the 
V-shaped method an excellent one, and while some cases will require 
a certain amount of resection, yet the principle involved in this 
V-shaped method can be utilized in almost all cases, regardless of 
the method used. The object, as said before, is to remove redun- 
dant tissue and place the septum in the median line. By cutting 
out these V-shaped pieces, as shown in Fig. 101, the redundant 
tissue is removed, and if the V-shaped cut is made at the base of 
the septum, so as to prevent any tendency to backward pressure, 
with one or two cuts made above, as shown in Fig. 101, and the 
septum is supported by means of a metal tube, no difficulty will be 
experienced in retaining the septum in position. 

From an operative standpoint septal deformities can be divided 
into two varieties : (1) Septal deflections without external deform- 
ity ; (2) septal deflections with external deformity. 



DEFORMITIES OF THE SEPTUM. 



305 



When the deflection begins at the base of the septum, a V- 
shaped cut should be made on the concave side of the deflection 




Fig. 101 — The v-shaped cuts are diagrammatic only. The position and direction of cut 
will vary in different cases. The dotted line indicates where the cut should be made on 
opposite side. 

close to the floor of the nose (see Fig. 101). In making this V- 
shaped cut the amount of tissue to be removed depends upon 
the angle of the deflection, care being taken to remove sufficient 
tissue, so that when the septum is placed perpendicularly there 
will be no backward pressure and the surfaces will come together 
as shown in Fig. 101, 3. As many more incisions should be made 
as are necessary to break up the resiliency of the septum, so that it- 
will swing freely from the top. These incisions may be made by the 
thin curved saw-blade, or, if the redundancy is 
extensive and the curvature in the septum is 
pronounced, then the V-shaped incision should 
be made. The rules governing the incision are 
based on (1) the breaking up of the resiliency 
of the septum by the removal of the V-shaped 
piece or pieces and simple saw incisions, or a 
series of punctures or perforations, as shown in 
Fig. 101, so as to weaken the septum and allow 
it to be moulded in the position desired. The 
best instrument for this method is the Harrison 
Allen septum-knife, as shown in Fig. 102, and 
(2) observing the blood -supply and carefully 
avoiding the cutting off of any portion of the septum and its mucous 
membrane by parallel cuts on the same side of the septum. 

20 



Fig 




Harrison Al- 
len's septum-knife. 



306 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

In certain deflections where the redundancy is excessive a large 
V-shaped piece must be removed. This can be done without 
injury to the mucous membrane on the opposite side. This is 
highly essential, so as not to disturb the blood-supply and thereby 
prevent ulceration. 

Originally, in the majority of cases I dissected up a flap of 
mucous membrane before making the V-shaped cut in the septum. 
This is not necessary in all cases. Neither could it be done where 
a number of cuts are necessitated. If, however, at the base of the 
septum it is necessary to remove a Jarge V-shaped piece of the 
cartilage, a flap of mucous membrane should be dissected back 
before the removal of the cartilage. After the removal of the V- 
shaped piece the mucous membrane should be carefully moulded 
back over the cut. It is not necessary to put in a suture, for if 
care be taken in inserting and placing the metal tube, it will suf- 
ficiently support and hold this flap in place. 

In deformities of the septum where the tissues have been 
forced down and the nose flattened, if it is desired to elevate the 
nose and place it in its normal position, the V-shaped cut should 
not be used. The bevel-edge cut, somewhat similar to the 
method used in lengthening shortened tendons, should be used 
instead. If, however, it is only desired to establish nasal respira- 
tion, the V-shaped cut should be used, and sufficient tissue re- 
moved at different portions of the septum so as to allow of its 
being moulded into line. 

The question of redundant tissue is necessarily involved in 
this V-shaped operation. Whether or not it is called redundant 
tissue matters little. The principle involved in this method can 
be illustrated in a board which has warped. While the actual 
length of the board is only slightly altered, in order to place it 
back in line a series of saw-cuts are necessary, the amount removed 
depending on the curvature. This is exactly the principle of this 
V-shaped cut. If this method is properly applied, it will remove 
redundancy either anteroposterior^" or perpendicularly. 

For the removal of this V-shaped piece I have always used a 
small curved saw previously described. In some cases, however, 
the making of the cut and the removal of the V-shaped piece is 
very tedious, and unless great care is exercised by the operator he 
will not remove a sufficiently large V-shaped piece of tissue to 
break up the resiliency of the septum. One case in particular in 
which I had great difficulty in removing the V-shaped piece 
suggested to me the advantage of an instrument which would 
make the cut and remove the tissue at the same time. Dr. George 
Fetterolf, who has assisted me in a number of septal operations, 
and this one in particular, afterward devised the V-shaped file- 
saw shown in Fig. 74. This is a most admirable instrument 
for the removal of this V-shaped piece. The instrument can bo 



DEFORMITIES OF THE SEPTUM. 307 

made at any angle desired, so that a large or small piece may be 
removed. It simplifies and shortens the operation very much. 

While in nearly all cases it is necessary to make more than 
one incision, it is rarely ever necessary to make more than two 
V-shaped cuts. The other incisions in the septum should be made 
with the thin saw or by a series of punctures merely to lessen the 
resiliency of the septum, and to permit of its being freely flexible 
and easily moulded into shape. The length of the cut in the sep- 
tum anteroposteriorly will depend entirely upon the extent of the 
deflection. This is also true of the width of the V-shaped piece 
to be removed. 

The advantage of the saw-cut in controlling the line of fracture 
when the bony septum is involved cannot be overestimated. The 
removal of the V-shaped piece of bone with a saw was a more 
difficult process than the removal of the piece of cartilage. The 
file-saw is of special advantage in those cases in which the bony 
septum is involved. A sufficient number of incisions should be 
made and sufficient tissue removed by the V-shaped cut to allow 
the septum to be placed in line and supported there by means of 
the nasal tube (see Fig. 93). There should be no pressure what- 
ever from this tube, as it acts merely as a support, and is not in- 
tended for pressure. Should swelling occur, however, after opera- 
tion, and the tension be too great, the advantage of this metal tube 
is that its diameter can be lessened by the introduction of a pair 
of forceps and the compressing of the tube. I have used these 
tubes for the past six years, and find them perfectly satisfactory in 
every way. They can be moulded to fit any nostril at the time 
of operation or afterward. This is a great advantage over the 
hard-rubber tubes. The tube may be left in position as long as 
the septum needs support. If there is any irritation produced by 
the tube, the nostril should be sprayed night and morning with 
camphorated albolene, one grain of camphor to the ounce of albo- 
lene. 

If the V-shaped cuts, as well as the straight cuts, are made at 
the proper point and of sufficient length and width, there will be 
little need for using the septum-forceps for breaking up the re- 
siliency. However, the small septal forceps of Roe (Fig. 95) or 
the small roll forceps as described on page 300 may be used in 
breaking up any remaining resiliency and to make the septum per- 
fectly pliable. 

The Sinexon dilator (see Fig. 97) is of great advantage in 
cases in which the obstruction is such as to occlude the nasal 
cavity and make it difficult to insert the cutting instrument. The 
dilator should be set so as to limit the amount of pressure, and 
passed through the obstructed side, using sufficient pressure to 
force the septum over far enough to allow of the free insertion of 
the cutting instrument. 



308 DISEASES OF THE ANTERIOR NASAL CAVITIES. 



Fig. 103.— Freer's knife for vertical incision in mucous membrane. 




Fig. 104.— Freer's elevators, sharp and blunt ends. 



Fig. 105.— Ballenger-Hajek's double-ended elevator. 





Fig. 107.— Self-retaining nasal speculum. 



Fig. 106.— Mallet. 




Fig. 108.— Fig.' 109.— Sep- 
Lewis sep- turn chisel, 
turn chisel. 



Fig. 110.— Septal bone-forceps 



DEFORMITIES OF THE SEPTUM. 



309 



The after-treatment is very simple. Unless there is evidence 
of infection, I think it is better not to use any spray or douche. 
If, however, the inflammation is rather severe, cold should be 
used during the first eight hours ; if necessary afterward, heat 
should be applied externally and a warm spray or douche of boric- 
acid solution, eight grains to the ounce, should be used in the 
nostril. 

For the submucous resection, either partial or complete local 
anesthesia is preferable ; but my own experience is that where the 
deflection is marked and the operation extensive, many patients, on 
account of the pain, are not able to withstand the operation, and it 
is necessary to give them general anesthesia. The various instru- 
ments required for submucous resection are shown in Figs. 103- 
110. 



/ 




Fig. 111.— Showing speculum in position and incision through mucous membrane to 

cartilage. 



When the operation is performed under local anesthesia, the 
nasal cavities are thoroughly cleansed and the external parts around 
the nose washed with soap and water and antiseptic solutions. I find 
satisfactory, for local anesthesia, using first a 10 per cent, solution 
of cocain diluted one-half with T ^p- solution of adrenalin chlorid, 
placed in each nostril on pledgets of cotton, the excess being re- 
moved so as not to run into the pharynx ; the cotton is left in con- 
tact with the mucous membrane for two or three minutes, after 
which powdered cocain is rubbed on the mucous membrane, after 
the method of Freer, which makes the operation painless and blood- 



310 DISEASES OF THE ANTERIOR NASAL CAVITIES. 



less. A self-retaining speculum is now introduced, and a vertical 
incision on the left side is then made about one-fourth of an inch 
from the tip of the nose, beginning at the upper part of the septum 
and extending to the floor of the nose (Fig. 111). The mucous mem- 
brane, perichondrium, and periosteum of the corresponding side 
are separated from the cartilage ^nd bone by means of special ele- 
vators, which should be moved in an upward and downward direc- 
tion in the long axis in order to prevent injuring the mucous mem- 
brane (Fig. 112). This having been done in as large an area as 
necessary, a vertical incision is then made through the cartilage to 
the perichondrium on the opposite side, following the line of the 




Showing elevator in position for separating mucous membrane from septum. 



primary incision of the mucous membrane. A suitable elevator 
is then placed through this incision, and the mucous membrane, 
perichondrium, and periosteum are separated, as on the opposite 
side, which should be done with great care, to avoid injuring or 
perforating the mucous membrane. Through the primary incision 
as much of the cartilaginous and bony septum is removed by 
piecemeal as is found necessary (Fig. 113). 

If it is necessary to remove the maxillary ridge and a portion 
of the vomer, a suitable chisel and mallet I find the most satis- 
factory. The nasal chambers are then thoroughly cleansed with a 
warm saline solution and both sides packed lightly with sterile 
gauze ; or some prefer the use of Bernay's sponge tampons. The 
packing is removed in twenty-four hours. 



DEFORMITIES OF THE SEPTUM. 



311 



After-treatment. — The patient should remain in a hospital the 
first night, when possible, on account of the constant oozing of 
blood and secretions of the nose. I usually advise the adminis- 
tration of \ grain of morphin and y^ of atropin, hypodermically, 
either before or after the operation. 

After the packing has been removed, the nasal cavity should 
be douched two or three times daily with normal saline solution, 
followed by a spray of bland oil ; and the patient should be espe- 
cially cautioned against violent blowing of the nose. 

The parts heal in from seven to ten days if the mucous mem- 
brane has not been torn. 




Fig. 113.— Showing removal of cartilage by means of a Brunning's forceps. 

Hamilton describes conditions found in 50 cases some years 
after the submucous operation had been performed. In 80 per 
cent, he found excellent results so far as function was concerned ; 
some crusting and bleeding in 2 of the remaining cases, though 
breathing was much improved. Perforations had occurred in 22 
per cent. Five of these experienced no inconvenience as a result 
of the perforation, 5 complained of slight crusting, 1 of crusting 
and bleeding, and 1 of an occasional whistling sound. 

Fig. 114 shows deflection of the septum with external de- 
formity involving the cartilage only, and I wish to call atten- 
tion to a very simple method of correcting this deformity. 
Figs. 114 and 115 need very little explanation. First, a small 
oblique incision (see Fig. 114) is made through the skin into the 
nasal cavity on the convex side of the deflection, just at the 



312 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

point of junction of the cartilage and bone, through which the 
small saw or file-saw is then inserted and a V-shaped portion 
of cartilage removed. This cut should extend down on the 
septum a sufficient distance to break up all resiliency, and the 







Fig. 114.— External deformity, showing line Fig. 115.— Showing v-shaped cut extending 
of incision. down on the septum. 

amount removed should be sufficient to render the cartilaginous 
portion of the nose entirely pliable. The external wound is then 
closed by one suture, as it is not necessary to make an incision 
over one-eighth to one-quarter of an inch in length. It is then 
sealed with collodion over cotton. 

The internal deformity is corrected the same as given above 
where no external deformity exists. It is of importance that a 
sufficiently large V-shaped piece be removed in order to render the 
septum perfectly pliable — in other words, to remove all redun- 
dancy. The principle involved in correcting the external de- 
formity is identically the same as for the correction of the internal 
deflection of the septum. The prime object in all septal opera- 
tions is to remove redundancy and break up resiliency. General 
anesthesia is preferable, although the operation can be done under 
local anesthesia. 

The variety of deflection shown in Fig. 92, 8 is frequently 
associated with lesions of the central incisors. This is especially 
true when the alveolar process of the upper jaw is thin and the 
tip of the root of the tooth is in close contact with the floor of the 
nose. The irritation produced by the accumulated secretion be- 
neath the projection on the septum causes pericementitis, and the 
method of correction of such deformity of the septum is shown in 
Fig. 92, 9, 10, 11. 

Each deflection will require some modification of any method. 
This is shown by the many methods proposed. The conditions 
found in many cases presented, however, will often necessitate 
a combination of methods rather than the following of any 
one. Of the methods introduced at various times, we have 



DEFORMITIES OF THE SEPTUM. 313 

Blandin's, in which a punch was used and the septum per- 
forated in front of the deviation ; Roberts's, in which the punch 
was also used, but the septum perforated at the point of greatest 
deflection, and held in position with pins ; Adams's and Roe's 
methods of crushing with forceps ; Bolton's method of serial 
incisions of the septum ; the well-known method of Asch, with 
the triangular flaps supported by Mayer's tubes ; Steele's modifica- 
tion of Bolton's method, in which the stellate incision is made by 
forceps devised by Steele for that purpose ; Sajous' punch, which 
is a modification of Steele's, producing a series of incisions, either 
linear, curved, or stellate ; and Hope's method, which is only a 
modification of Steele's or Sajous'. 

Asch Method (as Modified by Thorner). — " The blunt separator 
is introduced into the narrowed nasal fossa to sever any adhesions 
that may exist between septum and turbinales and to discover the 
presence of posterior obstructions. If found, they are opened 
with the sharp instrument, which is constructed after the fashion 
of a gouge. Should at this stage a brisk hemorrhage occur, which 
is, however, rare, it is readily controlled with an iced spray. The 
Asch strong cutting scissors are now introduced parallel to the 
floor of the nose, the narrow blunt blade into the narrow side 
just over the line of greatest convexity, while the sharp blade 
within the concavity is just opposite the narrow edge, so that a 
plane drawn through their two edges would form a right angle 
with the plane of the septum. This is a very important rule. By 
now firmly compressing the handles of the instrument the blades 
are closed and the sharp one cuts through into the opposite side 
with a distinct and audible snap. The scissors are now completely 
withdrawn and re-introduced without delay, but in a vertical 
direction and as near as possible at a right angle with and prefer- 
ably just opposite to the center of the line of the first incision. 
The second incision is then made by firmly closing the handles, 
leaving two incisions which intersect each other, and the instru- 
ment is then withdrawn from the nose. The four segments result- 
ing from the crucial incision are now forcibly pushed across the 
median line into the concavity by the finger introduced into the 
narrow side, care being taken that they are thoroughly fractured 
at their base, as on this fracturing process depends the destruction 
of the resiliency of the deviated portion of the septum, and conse- 
quently the success of the operation. The Asch compressing 
forceps is now introduced, one blade in each nostril, and the seg- 
ments of the septum compressed by closing it firmly, thereby not 
only straightening the septum still further, but also causing the 
broken segments to overlap each other in the concavity. By this 
process of overriding the second condition of success, in addition 
to destroying the resiliency, is given to shorten the longer line of 
the deviated to the shorter one of the straight septum. Thus the 



314 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

geometric axiom that the straight line between two points is the 
shortest to which reference was made is carried out. By this time 
the hemorrhage is usually quite brisk, but is controlled to some 
extent by the blades of the compressing forceps. It should be 
understood, however, that the forceps is simply meant as a com- 
pressing forceps, and any rolling, rocking, or wabbling motion 
should entirely be avoided. After removal of the forceps an iced 
antiseptic or sterile solution is sprayed in both nostrils and a tube 
introduced into each side, the largest one that can be introduced 
into the previously stenosed side without exerting any force, and 
a smaller one into the other nostril, thus providing, by even 
pressure, arrest of the hemorrhage and support of the septum/ 7 

In Ingals's method the incision is made with a knife from the 
top to the bottom of the septum, dissecting up a flap of mucous 
membrane and resecting elliptical-shaped pieces of cartilage suf- 
ficient to allow replacement, care being taken not to injure the 
membrane covering the other side of the septum. The flap is 
then turned down and stitched. 

Watson 1 s {A. W.) Method. — " An incision is made on the con- 
vex side of the septum, from behind forward, just beneath the 




Fig. 116 





method. 



angle of the deflection, following the angle to its anterior extrem- 
ity and then curving upward for a short distance. The incision is 
made on a bevel or obliquely to the perpendicular. The incision 
is not carried through the mucous membrane of the opposite or 
concave side if possible. The upper part of the septum is then 
pushed over the lower portion into the opposite side, thus overlap- 
ping the lower portion. The same principle is applied when the 
angle is perpendicular, the incision then being made behind the 
angle from above downward, the bevel being made from behind 
forward. An incision is also made at the base, forward from 
the first incision, forming a triangular flap. 

" The posterior edge of the anterior portion is then pushed over 
the posterior portion. If, as frequently occurs, both a horizon- 
tal and a perpendicular angle exist, both of the incisions are made, 
the incisions meeting at the base. The anterior fragment is first 



DEFORMITIES OF THE SEPTUM. 



315 



made to overlap the posterior, and then the upper portion, includ- 
ing the anterior portion, is made to overlap the basal portion. 
This forms a double locking and holds the anterior portion, which 
has no other support, firmly in a straight line. When the deflec- 




Fig. 117.— Showing line of incision in horizontal angle. 

tion extends into the bony portion of the septum, a very common 
condition, the bony deflection is broken and replaced with forceps, 
there being no need for cutting or overlapping of the bony portion, 
as, when broken, the fragments slide on each other and thus take 




Fig. 118.— Showing lines of incision in case of double angle (horizontal and perpen- 
dicular). 

up the redundancy, and, as the union is bony, there is no tendency 
to return of the deformity. 

" If the septum is thickened below the horizontal angle, the 
thickened base, which protrudes into the formerly obstructed 



316 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

naris, should, either immediately or after the parts are healed, be 
dealt with as if it were a spur by saw or forceps. If the sep- 
tum is thin in the lower part and projects unduly into the naris, it 
may be broken into a perpendicular position in line with the upper 
portion, thus increasing the overlap. The bony base soon unites 
by bony union. 

" After the parts have been placed in line a folded piece of 
gauze, iodoform, or other antiseptic gauze, long enough to extend 
the length of the former deflection and about one-third to one-half 
inch wide and thick enough to just pass easily into the naris, is 
placed in the formerly obstructed side. This dressing is changed 
every four days until the septum is firmly healed, about four 
weeks. 

" The instruments used are three knives and a septum forceps, a 
straight knife, like a tenotome, but with longer shank ; the same 
width blade at an obtuse angle ; and one with small blade bent 
on the flat almost to a right angle and sharp on both edges. The 
first two are used for the horizontal incision, the last for making 
the perpendicular incision. The forceps is a modification of 
the Adams septum forceps, the fenestrum between the blades 
being lengthened to an inch and a quarter, in order to be able to 
reach the bony part of the septum as well as the anterior portion ." 

Gleason's method, which also preserves the resiliency of the 
septum and uses the flap to hold it in position, consists in a U- 
shaped bevel incision at the base of the septum, so as to surround, 
excepting above, the whole deflected area. He then denudes the 
convex edge of the flap and concave edge of the base of the septum, 
and forces the flap through the incision. It is held in place by its 
elasticity. The technic is as follows : 

After cocainizing the tissue, the septum on the obstructed side 
is sawn transversely close to, and parallel with, the floor of the 
nose, until the teeth of the saw have penetrated somewhat deeply 
into the cartilage or bone. The direction of the sawing is then 
somewhat rapidly changed, until it becomes nearly vertical. Care- 
fully retaining the saw in a position parallel to the intermaxillary 
suture, the sawing is continued until a U-shaped incision has been 
made through the septum, surrounding, except above, the whole 
deflected area of the septum. This cut is larger on the convex 
side of the septum ; the smaller size of the U-shaped cut is on the 
concave side of the septum. As the result of the sawing, there is 
produced a buttonhole with bevelled edges through the septum, 
covered by a tongue-shaped flap. 

This tongue-shaped flap is thrust through the buttonhole in the 
septum with the tip of the operator's forefinger, and the parts 
assume the position shown in Fig. 119. The success of the opera- 
tion depends largely upon the care that is exercised in thrusting 
the flap completely through the septum. The finger-tip of the 




DEFORMITIES OF THE SEPTUM. 317 

operator, carrying the lower edge of the flap before it, is thrust 
through the septum until its further progress is prevented by the 
outer wall of the formerly unobstructed nostril. The finger-tip 
is then slightly withdrawn, and is made to feel along the posterior 
edge of the flap, to assure the operator that the posterior edge of 
the flap has completely cleared the posterior edge of the button- 
hole as far- up as the saw-cut has 
extended. The same maneuver is 
executed along the anterior edge 
of the flap. If the flap consists 
largely of bone at its upper por- 
tion, the bone will be fractured 
across the neck or upper portion 
of the flap, and will giye way with 
an audible snap. Under such cir- 
cumstances the resiliency of the 

n • -i j 1,1 • Fig. 119.— Vertical transverse section 

flap IS destroyed, and there IS no through the anterior portion of the 

fpnrlpnov for it to nn^ bqplr ao^in nose, showing position of the septum 
tendency lor It to pdSS UdCK again after the tongue-shaped flap has been 

through the buttonhole, assume its s^um hr ° ugh the buttonhole in the 
former position in the formerly ob- 
structed naris, and reproduce the original condition. If, how- 
ever, the neck of the flap is not fractured during the manipu- 
lations for clearing the anterior and posterior edges of the flap 
from the buttonhole, an effort should be made to fracture the 
neck of the flap by pressing the finger-tip firmly against it from 
below upward, the neck of the flap being by this means bent 
nearly to a right angle. Nevertheless, if the neck of the flap con- 
sist entirely of cartilage, as is sometimes the case in young sub- 
jects, where the deflection involves only the most anterior part of 
the septum the cartilage will not be fractured, nor will its resili- 
ency be greatly lessened. Only under such circumstances is sup- 
port needed during the healing process. 

As a means of support after the operation, the author's nasal 
tube described in Fig. 93 (or the Harrison Allen nasal tube), may 
be used. This tube is intended for support only, and should exert 
no pressure whatever. "When a tube is required, it is best to 
allow it to remain in position for the first forty-eight . hours after 
the operation, spraying an alkaline solution through it in order to 
keep it free from mucus. After the first forty-eight hours the 
tube should be removed, in order to cleanse it, as well as the nos- 
tril, daily, and the condition of the septum should be inspected. 

Killiari 's Jlethod (Submucous Window Resection). — " Under local 
anesthesia an incision is made on the convex side about .5 cm. 
back of the movable edge of the septum, not parallel to it, 
but a little oblique. The upper end is 1 cm. or more further 
back ; the first cut should pass completely through the mucous 
membrane and a little way into the cartilage. The elevation of 



318 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

the mucous membrane of the incised side can now be undertaken. 
Begin the elevation by first carefully dissecting the mucous mem- 
brane from the cartilage for a distance about .5 cm. with a 
sharp elevator, then in this narrow, undermined place put the 
blunt elevator, with w T hich the mucous membrane can quite easily 
be elevated backward, upward, and downward from the cartilage 
and bone. The elevation should extend as far as possible back- 
ward and upward. 

" The deviations and ridges on the forward part of the septum 
are, as a rule, so markedly bent and coming so near the floor of 
the nose that it is nearly impossible to elevate the membrane 
from around and under them until the cartilage and bone have 
been resected. In order to elevate the mucous membrane from 
the concave side, cut through the cartilage in the vicinity of the 
mucous incision, which is accomplished with the sharp elevator. 
Begin at the upper part of the mucous membrane incision, place 
the sharp elevator against the cartilage, and scratch in line of in- 
cision until the instrument passes through. 

" As soon as the cartilage is perforated and the opposite mucous 
membrane has been elevated a little with the sharp elevator, the 
blunt elevator is brought into use. It is used in about the same 
way as before. It should always be kept tightly held against the 
cartilage and its movements watched through the mucous mem- 
brane, which can easily be seen by looking into the nasal cavity of 
this side with the aid of a speculum. 

" When the mucous membrane has been loosened to a large 
extent from both sides of the septum the actual resection begins. 
The resection is done by separating the two elevated mucous lay- 
ers with the use of Killian's nasal speculum. One blade passes 
through the cartilaginous incision, while the other is placed be- 
neath the membrane first elevated. This leaves the septum be- 
tween the two blades and the two mucous layers on the outside. 
The cartilage is generally removed with Hartmann's forceps and 
the corn-forceps. A groove above and below is nipped away 
from the septum with Hartmann's forceps and then the interlying 
cartilage is twisted away with the corn-forceps, or Killian's carti- 
lage-knife may be used. 

"Bone resection is done with the Hartmann forceps, except 
the forward end of the vomer, which requires a special technic. 
After the removal of the cartilage, which rests upon this periostial 
covering, the periosteum must be severed and separated from 
the bone. In using Killian's chisel the cutting part of the chisel 
is placed on the lowest forward end of the vomer on a level with 
the nasal floor. When the base of the forward wedge-shaped 
part of the vomer has been chiseled through, it is detached with 
the chisel ; then the most difficult part of the operation is over. 
When the mucous membrane has been elevated from both sides of 



DEFORMITIES OF THE SEPTUM. 319 

the lower part of the septum and has also freed the ridge as far as 
possible from its mucous covering, it is then advisable to cut 
away, with Hartmann's forceps, the thin vomer beneath the ridge. 
The space between the two mucous layers should now be cleared 
of blood, pieces of septum, etc., and the two layers placed one 
against the other ; then both sides should be examined to see if the 
septum is now completely in a straight line. Every point of 
the septum projecting beyond the median line must be removed, 
so that, after healing has taken place, the mucous membrane will 
stretch in an even surface from the edges of the window resected 
from the septum. 

" The two layers of mucous membrane are held in place by the 
use of tampons, which are left in place for two days." 




Fig. 120.— Alligator bitiug-forceps. 

Ballenger's method is as follows : " Under local anesthesia the 
Killian incision is made, being careful to carry the incision through 
the mucous membrane and perichondrium and a little way into the 
cartilage. Where there is a sharp, angular ridge coming well 
forward, Hajek's incision is used. The incision is made on the 
left side of the septum, regardless of the side of the convexity, as 
in right-handed operators it leaves the left hand free to manipulate 
the tip of the nose during the incision. To elevate the mucoperi- 
chondrium Hajek's semi-sharp elevator is used to start the eleva- 
tion and the dull ovoid elevator is used to complete it. The next 
step in the operation consists in completing the incision through 
the septal cartilage. This is done with a small short-bladed scalpel. 
The scalpel should follow the general direction of the original in- 
cision through the mucous membrane, and should be manipulated 
delicately, cutting the cartilage, layer by layer, until the mucoperi- 
chondrium of the opposite side is reached. Having completed the 
cut through the cartilage, the semi-sharp elevator should be intro- 
duced through the incision with its flat surface resting against the 
opposite side of the cartilage. 

" When the elevator has separated the mucoperichondrium for 
about one-fourth inch the ovoid elevator is introduced in its stead. 
Having elevated the mucoperichondrium upon the two sides of the 



320 DISEASES OF THE ANTERIOR NASAL CAVITIES. 



septum, the swivel-knife should be introduced into the lower part 
of the incision, care being exercised to have the prong-tips within 
the cavity of the mucoperichondrium while the blade, resting be- 
tween the tips, engages the cartilage. 

" To facilitate the insertion of the prong-tips, the Killian spec- 
ulum rhinoscopia media is used to separate the muco- 
perichondria until the prong-tips are inserted and 
the blade is pushed backward through the cartilage 
one-fourth inch or more. Having successfully placed 
the prong- tips astride the incised cartilage and be- 
tween the mucoperichondria, the knife should be 
pushed backward along the floor of the nose, hug- 
ging the superior border of the vomer until it reaches 
the most posterior portion of the cartilage. 

il The prong-tips should then be directed upward 
and forward, hugging the anterior-inferior border 
of the perpendicular plate of the ethmoid until it 
reaches the region of the nasal bones. It should 
then be pulled downward parallel with the ridge of 
the nose until it merges through the superior por- 
tion of the incision. The anterior tip of the excised 
cartilage should be seized with a pair of dressing- 
forceps and removed through the incision. The bony 
crest or ridge is removed submucously with Freer's 
special gouge, mallet, and forceps, and the removal 
of the deflected portion of the perpendicular plate by 
means of the Kyle submucous saw. Both nostrils are 
lightly but firmly tamponed with sterilized gauze." 
Freer's Method ( Window Resection). — " The in- 
cision in the mucous membrane necessarily varies 
according to the type of deflection. For the frequent 
double-angled deflection, the incision is made in the 
shape of a capital L looking backwark, the vertical 
cut following the angle of the vertical deflection and 
beginning high up on the septum above the devia- 
tion, the horizontal cut extending forward from the 
bottom of the vertical one along the crest of the 
horizontal deflection if it be acute and project greatly. 
If it be little prominent the incision is made along 
the nasal floor ; the cut should extend to the very 
front of the septum in most cases. This outlines 
anterior flap with its base forward. The posterior extension 
of the horizontal cut, which gave the older incision the form of an 
inverted T, Freer no longer uses. 

"The incision for the crest-like deflections varies with their 
depth in the naris. For those extending to the front of the nostril 
an incision is made from behind, forward along the whole length 



Fig. 121.— Swivel- 
knife. 



an 



DEFORMITIES OF THE SEPTUM. 321 

of the crest of the deflection, curving the cut upward at the front. 
This outlines a superior instead of an anterior flap. 

" Most of the crest-like deflections begin far back in the naris 
in or near the bony septum, and for these a single vertical incision, 
reaching from the nasal floor high up on the septum, is made just 
in front of the beginning of the deflection, and the resection is 
conducted for this, for in this type of deviation there is no de- 
flection to remove from the front of the naris, and the vertical 
incision opens the way at once to the deep-seated deviation in the 
bone. 

" Where the anterior inferior free border of the septum is dis- 
placed into the naris of the concavity sufficiently to obstruct 
breathing, causing the anterior plane of the vertical angle of deflec- 
tion to be across both nostrils, the resection is commenced by an 
incision on the concave side, and as much of the deflection is dis- 
sected out from this as can be reached. If the deviation ex- 
tend far back into the bone the usual vertical cut is made along 
the vertical angle on the side of the convexity and the dissection 
continued from this." 

Sidney Yankauer's Method. — " A vertical or nearly vertical in- 
cision is made through the mucous membrane and perichondrium 
on the convex side in such a position that its lower end corre- 
sponds to the anterior edge of the nasal floor. The incision is then 
carried outward along the mucocutaneous junction half-way to the 
outer nasal wall. The incision passes just behind the anterior 
nasal spine and just in front of the beginning of the devia- 
tion. When the cartilage passes obliquely across the nasal spine 
and projects from the opposite nostril the incision is made 
at the point of crossing. It extends about three-fourths inch 
upward from the nasal floor and its upper end should be at least 
one-half inch from the dorsum of the nose. As none of the car- 
tilage in front of this incision is removed a bridge of cartilage is 
left which is attached below to the nasal spine and above to the 
notch between the nasal bones. This bridge of cartilage sup- 
ports the dorsum of the nose, and should always be preserved to 
prevent subsequent deformity. With a sharp elevator the mucous 
membrane and perichondrium are separated and reflected upon the 
outer nasal wall. When the tip of the nose is raised the opening 
in the septum will now be found to be parallel to and just behind 
the nostril, and the field of operation obtained through this 
opening will be as large as could be obtained through the nostril 
itself. A perforation is now made through the cartilage by scrap- 
ing it with a sharp spoon. The sharp spoon is preferable to the 
knife for this purpose, as the exact thickness of the cartilage is an 
unknown factor and the opposite mucous membrane may easily be 
lacerated at this point. The absence of resistance indicates at 
once that there is no more cartilage beneath the spoon. When a 
perforation has been made in the cartilage a hook-shaped elevator 
21 



322 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

is introduced through this perforation and the mucous mem- 
brane of the opposite side separated. When the elevator is first 
introduced it causes a slight elevation of the mucous membrane 
which can be seen through the opposite nostril, and the separation 
of the mucous membrane may be controlled in this way. The 
cartilage is then removed piecemeal by means of cutting forceps 
of any kind. The beginning of the bony deviation will be found 
immediately under the cartilage and must be removed. Some- 
times the cartilage, instead of being attached to the upper border 
of the anterior nasal spine, has been dislocated and is attached to 
the spine laterally. In such cases the cartilage is separated from 
the bone by a layer of tough, fibrous connective-tissue, which 
passes through the septum from one perichondrium to the other 
and conceals the bone. This layer of tissue must be cut through 
with the knife, care being taken not to injure the mucous mem- 
brane flaps. As the exact anatomical relations vary in the differ- 
ent cases, this is at times a difficult and confusing part of the 
operation ; but if the lowest part of the septum, immediately 
behind the spine, is properly exposed at an early stage of the 
operation the subsequent manipulations are very much facilitated. 
Having cleared the anterior part of the deviation, a speculum is 
introduced into the septal opening or the flap may be held back 
with a retractor in the hands of an assistant ; the separation of the 
mucous membrane is then continued backward, especial care 
being used in prying it out of the angle on the hollow side of the 
septum. At this stage of the operation it will be noticed that 
each time the patient takes a deep inspiration the mucous mem- 
branes are separated by the inrushing air, the cavity in the 
septum becomes as large as the two nostrils together, and the car- 
tilage and bone stand out prominently between them. The flaps 
are thus held apart automatically. As the deeper parts of the 
septum are reached this ballooning of the septum becomes more 
distinct. All the deviated parts of the septum, cartilage above 
and bone below, can now be easily removed with cutting- or biting- 
forceps, until the remaining edge is exactly in the median line. 
The mucous membrane is then replaced. The nose is packed in 
the following manner : A strip of gutta-percha tissue about one- 
half inch wide is placed in the nostril well behind the incision and 
laid against the septum so as to cover the incision and prevent 
the gauze from being packed into the wound. The entire nos- 
tril is then packed lightly with iodoform or aristol gauze. The 
vestibule of the nose is filled with cotton. The packing is 
held in place with the finger and the strip of gutta-percha i& 
withdrawn." 

The Douglass operation differs from the Asch in that it is per- 
formed with a special perforator and knife, and not only the 
crucial incisions, but the crossing incision at any point is avoided. 
The incisions are made along the lines of deflection in whatever 



DEFORMITIES OF THE SEPTUM. 323 

direction and as far as they may lead, in the belief that these are 
the seats of old fractures. 

The next step is to force the septum over into the unobstructed 
side with the finger and hold in place by means of splints. 

Moure's Operation. — " The operation is performed with a 
special pair of scissors resembling the Asch vertical one, having 
the blades set at an obtuse angle to the handles. The first cut is 
made as close as possible to the nasal floor and as far back as pos- 
sible. The second cut is made without withdrawing the scissors, 
as close as possible to the dorsum nasi. The two incisions, which 
must not meet, form a movable triangular flap, which is pushed 
with the finger into the opposite nostril. 

" A special splint is inserted and adapted, by means of a dilat- 
ing forceps, to the septum and left in position seven or eight days, 
at the end of which period the septum is generally fixed in posi- 
tion. This operation avoids crucial incision and separates the 
septum from the maxillary crest. The scissors are inserted with- 
out regard to the location of the deviation. It is very rapidly 
performed, in from one-half to two minutes, and can be done under 
nitrous oxid or cocain." 

W. E. Casselberry's Operation. — " When the deflection is of the 
bulging or angular sort, involving the wdiole cartilage and en- 
croaching perhaps upon the bone, therefore situated well within 
the nostril, a crucial incision, the lines crossing at the point of 
greatest convexity and extending well to the circumference of 
the bulge, is made by a bistoury entirely through the septum from 
one side to the other. The little finger is then inserted into the 
narrow nostril and the septal fragments pushed forcibly into the 
opposite nostril. In order to destroy the resiliency of the top 
fragment it may be necessary to weaken its base by an additional 
cut, but not extending through its whole thickness. The slightly 
overlapping fragments are then kept in place by an iodoform 
gauze packing in the narrow nostril which may be replaced in 
three days by a suitable sized Asch tube, which is worn for six 
weeks to serve as a splint. If the tube is not at hand the gauze 
packing may be continued, or a splint extemporized by wrapping 
a piece of tin with iodoform gauze till the proper size and shape 
are attained." 

John 0. Roe's Method. — "After the preliminary operations for 
excrescences or redundancies have been performed, and any neces- 
sary incision made, the fenestrated forceps, with blades of suitable 
size, is introduced with the ring or female blade on the concave 
side of the septum, the male blade being very readily crowded 
into the obstructed nostril on the convex side. The forceps is 
so constructed that the blades are separable like those of an obstet- 
ric forceps, which is readily locked after the blades have been in- 
troduced. When the blades are in proper position the lower por- 
tion or the junction of the cartilage with the anterior portion of 



324 DISEASES OF THE ANTERIOR NASAL CAVITIES, 

the vomer should be fractured ; then the junction of the cartilage 
with the perpendicular plate of the ethmoid, so that all the 
resistance or elasticity has been entirely overcome. The selec- 
tion of the blades in each particular case should be made with 
reference to the size or length of the deflection. In some cases, 
however, the deflection in the osseocartilaginous portion will be 
very much greater than the size of the meatus, so that a ring-blade 
large enough to cover the deflection cannot be introduced, in which 
case a portion of the deflection can be broken up at a time, the 
position of the forceps being changed or different-sized blades 
selected, according to the site of the part to be fractured, and new 
portions of the deflection grasped until the deflected portion has 
been sufficiently broken up and elasticity removed to allow it to be 
placed in the median line. 

In many cases there is a deflection or dislocation of the tri- 
angular cartilage at its attachment with the vomer, associated with 
a dislocation or deflected attachment of the vomer itself along the 
maxillary ridge. This can ordinarily be corrected by forcibly 
holding the forceps down to the floor of the nose, and by catching 
the lower portion of the ring-blade over the stump of maxillary 
ridge a sufficient pressure can be brought by the single blade to 
fracture the attachment and set the septum over to its proper 
position. In case ossification is too firm the operation can be facil- 
itated by loosening with the chisel or sawing the bone at its lower 
attachment. 

" When there is a double deflection, forming a l zigzag ' or 
' sigmoid ' deflection, the center of which is usually found along 
the line of the attachment of the triangular cartilage with the 
perpendicular plate of the ethmoid, it is necessary to reverse 
the blades of the forceps for the two sides, forcing one portion 
over in one direction and the other portion in the opposite direc- 
tion. But, owing to an occasional difficulty in some cases of main- 
taining the parts in position after a double operation, it is fre- 
quently advisable to make each deflection a separate operation, the 
second one being performed when the parts are thoroughly fixed in 
place after the previous operation. 

" After the forceps is used and before the dressing or support 
is introduced the septum should be carefully explored with the 
small nasal spatula or with the finger, to ascertain if all the elas- 
ticity of the fractured portion has been overcome. If any elas- 
ticity still remains this should be overcome by the use of the 
forceps at the point of resistance. When this has been accom- 
plished the septum should be put in the median line preparatory 
to the introduction of the dressing. For this purpose the nasal 
spatula or perichondrium elevator is admirably adapted, although 
in many cases the flat-bladed Adams forceps, having parallel 
blades, is exceedingly serviceable for putting the fragments and 
the entire septum exactly in the median line. 



DEFORMITIES OF THE SEPTUM. 325 

" Method of dressing or support : A plug made of sterilized 
cotton wrapped around a small metal plate to give it firmness and 
of the requisite size to fill the nostril comfortably. This is placed 
in the previously occluded nostril or the convex side toward 
which the septum has been deflected. In case there has been a 
double deflection, one should be placed on each side opposite the 
point of previous convexity, the other nostril, or the formerly 
concave side, where no support is necessary, being left free for 
respiration." 

J. Price Brown Method. — Two longitudinal cuts are made 
from before backward through the septum with a thick saw ; 
these are made obliquely from the convex side and about a half 
inch apart through both mucous membranes, the lower cut being just 
about the superior maxilla ridge. To relieve the anteroposterior 
tension a cross-cut is made completely through both mucous mem- 
branes and cartilage, converting the two straight lines into the 
figure H. They are pushed in their normal position, their edges 
sliding over each other and retained in position by the use of the 
rubber splint, a single one on the convex side being the only 
one needed. 

The points of advantage claimed are : 

First, that, as the curvature of the cartilage from above down- 
ward gives it a greater width than it could occupy if it were 
upright in its normal position, the two longitudinal cuts should 
be so managed as to remove two long slips of the septal cartilage, 
and at the same time be made at an oblique angle, so that the cut 
edges can slide over each other. 

Second, that the cross cut of the H should be very decidedly 
oblique, extending at right angles beyond both of the parallel in- 
cisions, and cutting through both mucous membranes and carti- 
lage, so that in replacing the segments the posterior central 
segment of the septum will slide forward over its fellow and the 
anterior one backward. 

Synechia. — A synechia is usually a bony, cartilaginous, or 
fibrous band extending from the septum to the lateral nasal wall. 
Although this is the common site of the svnechia, vet a similar 
union may exist between the turbinate, and is as true a synechia 
as if attached to the septum. Synechia? may be divided into con- 
genital and acquired. 

Congenital. — It is difficult to establish the etiological fact 
underlying a congenital synechia, but when observed in the very 
young we are warranted in classifying it as congenital, especially 
if it be cartilaginous or bony in character. The common site of 
adhesion is between the middle turbinate (Fig. 122) and the septum, 
although it may occur in any location. 

Acquired. — In the acquired variety, the condition requisite to 
the formation of synechia is desquamation or ulceration involving 



326 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

both septal and turbinal walls. While usually the ulcerative sur- 
faces come in direct contact, permitting of adhesion, yet it is possible 
to have a fibrous adhesion due to the building up of the plastic 
material from the ulcerated surfaces, until separated portions are 
brought together. As this band is of inflammatory origin in its 
early organization, the two surfaces will be very close together ; but 
as contraction occurs, and such contraction always does take place 
in inflammatory organized tissue, the septal and turbinal walls are 
still further separated, and the junction becomes more band-like. 
The ulceration necessary to form a synechia may be brought about 
in a number of ways — irritation from foreign bodies, in simple 
chronic and hyperplastic rhinitis, in which from pressure ulcerative 
processes occur, or from surgical interference for the removal of 




Fig. 122.— Vertical section, looking backward, showing redundancy of the septum on 
the right side, with false union (synechia) between it and the adjoining turbinate. Punct- 
ure of the right antrum through the alveolar route would fail, and entrance would be 
made into the enlarged nasal cavity (after Cryer). 

nasal obstruction, or following the application of the thermocautery 
or escharotics. Owing to the obstruction to nasal breathing in either 
the congenital or acquired synechia, there may be brought about 
inflammatory processes in the nasal mucous membrane of the 
obstructed nostril, which, in turn, from the interference with 
respiration and the accumulation of secretion, may involve the 
nasopharynx and pharynx. 

Treatment. — As this condition always interferes with nasal 
respiration, its prompt removal is necessitated. This should be 



COLLAPSE OF NASAL ALM. 327 

accomplished with as little injury as possible to the healthy struct- 
ure surrounding the attachments. If the synechia be of bony 
formation, its removal can be accomplished by means of the file- 
saw (Fig. 74). The advantage derived from this V-shaped cut is 
that during and after the healing process the tissues draw away 
from each other. Care should be taken to remove a little tissue 
below the surface of the points of attachment of the synechia, 
thus farther separating the inflamed surfaces and preventing sub- 
sequent union due to inflammatory reaction. The nostril should 
be loosely packed with absorbent cotton, saturated with hydrogen 
peroxid, repeatedly changed. Thorough cleansing with a saturated 
solution of boric acid should be insisted upon. Should any exuberant 
granulations occur at the point of removal, these should be touched 
with 20 per cent, chromic-acid sol ution ; or, if they are only slight, 
a 3 per cent, chlorid-of-zinc or 5 per cent, formalin solution will 
suffice. The patient should be seen until complete healing has 
occurred, otherwise the synechia will re-form. 

In order to give the best results, the operation for the correction 
of septal deformities should not be done before the sixteenth to 
the eighteenth year of age; in other words, not until the facial 
bones are completely formed. 

3. COLLAPSE OF NASAL AL>£. 

Collapse of the nasal alee or narrowing of the nostril may be 
brought about by faulty formation of the lateral cartilages, or 
may be due to the fact that in early childhood there was inter- 
ference with nasal respiration as well as inability of the child to 
breathe through the nose, and the orifice remained undilated from 
lack of use. Also, from non-use the dilators of the nasal alas lose 
their tone and the nostrils collapse. Again, from the contour of 
a long, pointed nose with a long, narrow, slit-like nasal orifice, 
there may be a tucking-in and narrowing of the nasal orifice, due 
to the action of the constrictor muscles. This collapse or narrow- 
ing of the nasal orifice brings about, through forced mouth-breath- 
ing, a variety of diseases of the pharynx and larynx. While there 
may be subsequent nasal inflammatory conditions, yet from the 
forced mouth-breathing, through inability to breathe through the 
nose, the symptoms will draw attention to the pharynx and larynx 
rather than to the nose. 

For the relief of this collapse or narrowing I have had satis- 
factory results from the use of a short, perforated silver tube, 
made for each individual case. The tube can be fitted within the 
nostril, and should not reach up as far as the bony septum. The 
patient is instructed to wear the tube from twelve to fifteen hours 
out of the twenty-four, or at night only. If this be persisted in 
for several months, much will be done toward relieving the col- 



328 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

lapse. From time to time the diameter of the tube can be 
increased to exert slight pressure. After a few weeks the patient 
becomes accustomed to wearing the tube, and in several instances 
I found that it had been worn, contrary to instructions, during the 
entire twenty-four hours, only removing it long enough for cleans- 
ing. As a rule, the patient complains more of the obstruction at 
night than during the day. This is possibly due to the venous 
and lymphatic stasis while in a recumbent position. In such 
cases it is better to have the tube worn at night only. This same 
method will, if persisted in, often relieve the obstruction caused 
by the tucking-in of the orifice, due to the contraction of the con- 
strictor muscles. 

When the alar cartilage is too sharply bent, so that it lies 
against the septum superiorly, the mucous membrane border may 
be dissected up and a small part of the upper edge of the cartilage 
removed submucously, after the method of Halle. Similarly, a 
small portion of the lower edge of the alar cartilage may be re- 
moved if the deformity is reversed. 

4. ULCERATION AND PERFORATION (CARIES AND NECROSIS). 

Ulceration. — Ulceration and perforation of the septum are 
closely allied processes. True, there may be ulceration that does 
not go on to perforation, and perforation may exist without pre- 
existing ulceration ; but, excluding congenital defects or trauma, 
perforations are preceded by ulceration. As an exciting factor in 
ulceration, irritation may come from without in the form of dust, 
as in occupation-rhinitis, or in any mechanical irritation. Again, 
ulceration may be due to vascular changes brought about by irri- 
tating material floating in the blood, as occurs in the uric-acid 
diathesis. Besides these irritants, systemic conditions which tend 
to passive congestion may, by the alteration in circulation, pro- 
duce a similar condition. Ulceration is not only due to the inter- 
ference with blood-supply, but, owing to the vascular change and 
passive congestion, there is a certain amount of itching and irri- 
tation within the nose, which gives rise to constant desire to pick 
at the septum. Deflections of the septum, especially the acute 
angular deflections, are liable to ulceration in their concave por- 
tion. This is due to the fact that the blood-supply is poorer at 
that point, owing to pressure, and also that at that, the dependent 
portion, there is marked irritation, owing to the accumulation of 
foreign material. In any interference with intestinal circulation, 
the nasal mucosa has a marked tendency to engorgement, with 
subsequent irritation and inclination to pick the nostril. This is 
especially marked in children, and is exemplified in children in 
whom the irritation is due to intestinal worms. The constant 
picking of the nose, with the subsequent abrasion followed by 



ULCERATION AND PERFORATION OF SEPTUM. 329 

infection from the finger-nails, will lead to ulceration. One patient 
seen at my clinic at the Jefferson Medical College Hospital, a boy 
seven years of age, had ulceration of the septum, which had gone 
on to perforation, in which there was a distinct history of intestinal 
worms and constant picking of the nose. 

While it may be difficult to explain some of the reflex causes 
of nasal irritation with ulceration, yet the fact remains unques- 
tioned. Moreover, ulceration may be brought about by foreign 
bodies or by pressure from intranasal growths, and may also be 
associated with chronic inflammatory processes involving the nasal 
mucosa. Again, nasal ulceration may be brought about by lesions 
of the cartilage, or a perichondritis which may be the result of 
some acute infectious fever or specific inflammatory process. In 
such cases the ulceration is a secondary process. The necrosis 
begins in the deep structures and ulcerates to the surface, although 
the common variety of ulcer of the septum begins by an abrasion 
of the mucous surface, followed by infection and gradual invasion 
of deeper structure, extending from without inward. In any 
cachexia or condition in which systemic nutrition is poor, there is 
a marked tendency to ulceration of the mucous membrane. Owing 
to the poor blood-supply of cartilage, this ulceration is quite likely 
to occur in the mucous membrane lining the septum. In the 
atrophic form of rhinitis, in which there is accumulated secretion 
within the nostrils, the irritation produced by it often leads to 
picking of the nose ; and by undue violence in this way ulcera- 
tion may be produced, although it is rare. Syphilitic ulceration 
is usually associated with syphilitic necrosis of the bone. Expos- 
ure to excessive heat or cold, causing sudden and rapid changes 
in circulation, may produce ulceration. The same is true of irri- 
tating fumes or vapors. Ulceration may follow the application of 
the actual cautery or the use of escharotics. Certain forms of 
ulceration, after irritation has been produced, are unquestionably 
influenced by bacteria. In the majority of cases, the bacterial 
infection and the part it plays in the progress of the ulceration are 
secondary. One patient coming under my observation, who has a 
simple chronic ulcer of the septum, says that if he is exposed to ery- 
sipelas, he always develops an attack of facial erysipelas. The 
so-called trophoneurotic ulcer is usually associated with systemic 
conditions or localized hemorrhagic areas. Ulceration is likely to 
occur in any age of life. In the very young and very old, how- 
ever, it is not so common. When occurring in the very young or 
in infants, it is always suggestive of congenital syphilis. 

Site. — The ulceration usually occurs in the mucous membrane 
overlying the cartilaginous septum, although from specific or infec- 
tious processes, that lining the bony septum will also be involved. 
As a rule, the ulcerative process is located in the upper two-thirds 
of the septum, although its position will depend upon the cause — 



330 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

whether it be due to external irritation or to circulatory interfer- 
ence. The common site for a simple, non-infectious ulcer, seen in 
individuals who frequently blow or pick the nose, is just within 
the nostril ; it, in reality, begins as a traumatic ulcer. Its size 
varies from a mere pin-head to the involvement of almost the 
entire mucous- membrane surface. The ulcer usually invades one 
nostril only, and when occurring in both nostrils is not symmetrical 
as to location. The discharge from the ulcerated surface varies 
with the cause, degree, and progress of the ulceration. With the 
exception of the specific ulcers — those due to specific inflammatory 
processes or due to foreign bodies — there is usually very little, if 
any, odor present. 

Treatment. — Owing to the great number of causes of ulcera- 
tion of the septum, it would be impossible to formulate a plan of 
treatment for all special varieties, and therefore only a general 
outline of treatment can be given, which must be directed toward 
the causative pathological influence and the improvement of the 
general condition, thereby increasing local recuperative powers. 
In many cases of septal ulceration, I believe that anxiety to relieve 
the patient of the trouble leads to too frequent applications, which, 
with the constant probing at the surface, tends to keep up the 
irritation. The general plan of treatment should consist in the 
thorough cleansing of the part and the careful and gentle application 
of such sedatives or astringents as are indicated by the nature of the 
ulceration. The grayish, sluggish, indurated ulcer usually requires 
stimulation ; while for the inflamed ulcer, with its boggy edges 
and edematous surrounding tissue, sedatives and mild astringents 
are indicated. Syphilitic ulceration, which is nearly always asso- 
ciated with necrosis and perforation, apart from local cleansing 
treatment, can be controlled only by systemic medication. In the 
sluggish form of ulcer, in which stimulation is required, it can be 
accomplished by curetment sufficient to produce reaction or, in 
reality, its conversion into an acute ulcer. The best stimulating 
solution that can be applied is the 20 per cent, chromic-acid solu- 
tion or a 3 to 5 per cent, chlorid-of-zinc solution, or nitrate of 
silver, 10 to 20 grains to the ounce. In using these solutions the 
milder solution should be used first, and the strength increased 
until the desired stimulation is produced, as a solution of a strength 
sufficient to act as an escharotic is to be avoided. In sluggish 
ulceration with very little induration, where there is considerable 
discharge from the ulcerated surface, a 3 per cent, solution of 
formalin usually produces a healthy granulating surface. Of the 
sedative agents to be used in the form of ointments, carbolized 
vaselin is one of the best vehicles for their local administration. 
To the ounce of carbolized vaselin may be added 4 grains of men- 
thol to 1 grain of camphor or 10 grains of boric acid. Yellow 
oxid of mercury, 8 grains to the ounce, is slightly stimulating, 



ULCERATION AND PERFORATION OF SEPTUM. 331 

but not to the point of irritation. The use of the powders is bene- 
ficial in some cases ; but quite often, by reason of a marked ten- 
dency to clotting or drying, their very presence produces irrita- 
tion. 

When powder is used, the patient should be instructed to fill 
the lungs and hold the breath just before the inflation of the pow- 
der into the nostril, so that the first respiratory act will be expira- 
tion, in this way obviating the drawing of the powder into the 
nasopharynx or larynx. I have obtained the best results from 
stearate of zinc to each ounce of which has been added 10 grains 
of pyoktanin or boric acid, although equally good results can be 
obtained from the use of salol or aristol, 3 grains to the ounce 
of stearate of zinc. 

Perforation of the Septum. — Perforation of the cartilagi- 
nous septum is not of common occurrence. In 5000 cases which I 
have seen within the last six years, I have found perforation occur- 
ring in the proportion of about 1 in every 200. Congenital defect 
with perforation is, indeed, rare. As to the cause of perforation, 
occupation seems to be an important factor, since individuals 
whose occupation subjects them to irritating dusts, fumes, or vapors 
present a number of instances of perforation. In these cases, the 
perforation is brought about by picking the nose with the finger- 
nail to relieve the irritation from the dust, thereby starting ulcera- 
tion, with subsequent perforation. The same condition may be 
caused by the inhalation of the bichromate-of-potash fumes, and 
may be found also in persons exposed to the irritation of the dust 
or the constitutional effects of phosphorus, chromic acid, arsenic, 
cement, and lime. 

One case of perforation w T hich came under my observation w r as 
unquestionably due to the exposure of the patient to the fumes pro- 
duced by the contact of acid with various metals directly over 
which he was working in the course of continual experiments. It 
began with ulceration, which gradually went on to perforation. 
In the constitutional conditions bringing about perforation, the 
necrosis begins within the cartilage, involving that primarily, 
possibly as a perichondritis, and the mucous membrane lining 
the septum undergoes necrosis from diminished blood -supply. 
This necrosis of the cartilage is found most commonly in the 
specific inflammatory processes, syphilis and tuberculosis — oftener 
in syphilis. Furthermore, it may follow the eruptive fevers or 
any of the infectious fevers, especially typhoid fever and diph- 
theria. Perforation may also be brought about by injury. That 
spurs or irregularities in the septum are etiological factors in per- 
foration, I doubt very much. While the projecting point is sub- 
jected to irritation, yet, as a rule, that irritation produces thickening 
and hyperplasia rather than ulceration, although in some cases 
ulceration and perforation may follow by reason of picking 



332 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

and external irritation. Perforation may also be caused by the 
careless use of escharotics or the galvanoeautery. One patient 
came under my care with a complete perforation of the septum 
following thermocauterization of a spur in the left nostril. Syph- 
ilitic perforations are usually associated with disease of the bone, 
either of the bony septum, or the turbinal bones, or both. One 
patient observed at the Jefferson Medical College Hospital Clinic 
showed syphilitic necrosis, with loss of the cartilage and bony 
septum, as well as of the inferior and middle turbinate bones. The 
peculiarity of perforation is that in many cases it produces no 



Fig. 123.— Ulceration and perforation of the cartilaginous septum. 

external deformity, although in some cases there is marked deform- 
ity. A peculiar perforating ulcer has been described by Hajek, 
which seems to be identical with " perforating ulcer" occurring 
in any other structure. This particular ulcer is not associated with 
any specific inflammatory process. 

Often the patient is not aware of a perforation until it is dis- 
covered by the physician. Perforation may be associated with 
other nasal conditions, either as a complication or as an allied proc- 
ess. The shape and size of the opening in the septum depend 
largely on its cause and location. When involving the cartilagi- 
nous portion of the septum, the perforation is usually round or oval. 
If, however, the bony portion is involved, it is usually very irreg- 
ular in shape ; although perforation of the bony portion, except- 
ing extensive syphilitic necrosis, is indeed rare, the cartilaginous 
part alone being usually involved. The perforation is usually 
single, although rare cases are reported in which there were sev- 



ULCERATION AND PERFORATION OF SEPTUM. 333 

eral small holes through the septum. The lesion may occur in 
any portion of the cartilaginous septum. Fig. 123 shows a per- 
foration on the center of the triangular cartilage. My own obser- 
vations show that the perforation most often occurs in individuals 
with the narrow, slit-like nasal cavity. 

Congenital defect of the septum is usually recognizable by the 
absence of any evidences of inflammation and by the fact that 
malformation and irregularity in the other facial bones are usually 
associated. Abscess of the septum, if allowed to rupture spon- 
taneously, is liable to lead to necrosis of the cartilage, with per- 
foration. The perforation due to the specific inflammations usually 
begins at the junction of the bone and cartilage, and shows a ten- 
dency to spread and invade continuous and contiguous structures. 
The simple ulcerations are usually limited to the cartilaginous 
structure, and are definitely outlined. Perforation may occur as 
the result of malignant growth, especially carcinoma. The vari- 
ous forms of rhinitis are believed to be causative factors in per- 
foration ; but I think that in the majority of cases the variety of 
rhinitis with which the perforation is associated is one which is 
brought about by irritants introduced from without, and the same 
irritant which produced the rhinitis is the exciting factor of the 
ulceration and perforation. The causes of nasal perforation may 
be grouped under the following general headings : 

1. Perforation due to faulty development. 

2. Perforation due to localized inflammatory processes. 

3. Perforation due to injury. 

4. Perforation as a local manifestation of a systemic condition 
seen in the specific inflammations, the infectious fevers, and rheu- 
matism. 

Sex. — Statistics on the subject show that sex has very little to 
do with the condition. Occupation, nasal deformity, and systemic 
conditions are the important factors. 

Age. — Perforation in the very young is of rare occurrence, the 
youngest case coming under my own observation — referred to under 
' Nasal Ulceration (page 329) — was seven years of age. The most 
common age is between twenty and forty, although perforation may 
occur at almost any age. As a rule, the ulceration which leads to 
perforation begins on one side. This is true if it begins as an ulcera- 
tion of the mucous membrane, finally involving the cartilage, which 
is always unilateral, as it is not likely that a point of ulceration 
directly opposite, on the other side of the septum, would occur at 
the same time. When breaking down occurs on both sides, it is 
that variety of perforation which is due to the primary involve- 
ment of the cartilage (necrosis) brought about by systemic infection, 
as in the specific inflammatory diseases or the infectious fevers. 

Pathology. — The pathological alterations which will cause 
perforation of the septum through necrosis do not differ from 



334 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

necrosis of tissue elsewhere. It may result from ulceration that 
spreads by continuity and contiguity of structure, necessarily pro- 
duced by the localized, limited blood-supply. The necrosis follow- 
ing this cutting off of blood-supply may or may not be due to 
infection. Although there is no one cause of nasal perforation, 
and although various causes may effect perforation with different 
degrees of rapidity, whether infected or non-infected, the ulcera- 
tive process, with liquefaction-necrosis and sloughing, is practically 
the same. 

Symptoms. — There are no special symptoms peculiar to per- 
foration, and it is often accidentally discovered during routine nasal 
examination. If, however, there is beginning deformity, this may 
call attention to the perforation. Once the perforation has occurred, 
very little can be done toward closing the opening, and treatment 
should be directed toward the prevention of further destruction 
of tissue by ulceration. 

Treatment. — In individuals subjected to irritants from with- 
out, in which ulceration is still associated with the perforation, the 
first efforts for their relief should be directed toward removal from 
such exposure. If, however, necessity compels their exposure, 
much can be done toward preventing further ulceration and also 
toward adding to their comfort, by protecting the nostril with a 
small piece of sponge and by the repeated cleansing of the nose 
w T ith a warm alkaline solution. There is nothing better for this 
purpose than tepid milk, to which has been added 2 or 3 grains 
of common salt to the ounce. Where the ulceration still continues 
at various points in the margin of the perforation, the area should 
be carefully cleansed and the perforation filled with a pledget of 
cotton saturated with carbolized vaselin, to which is added benzoic 
acid, 2 to 5 grains to the ounce. If there is much bleeding, 
astringents are indicated. Should they be necessary, cocain should 
be first applied, and the margins touched with the acid nitrate 
of mercury. When this drug is used, it should be followed by an 
ointment of carbolized vaselin to which has been added 3 to 5 
grains of the yellow oxid of mercury to the ounce. In perfora- 
tion due to syphilitic origin, resort to the constitutional treatment 
is imperative. As a rule, the perforation occurs in the tertiary 
stage, and the iodid of potassium alone is indicated. This should 
be pushed to its full physiological effect, regardless of dosage. 
Perforation due to tubercular infection does not tend to heal, and 
gradually invades continuous structures. Treatment should be 
directed toward the thorough cleansing of the parts. If the proc- 
ess be purely a local one, or lupoid in character, thorough cauter- 
ization may eradicate the infected tissue. As a rule, however, it 
is associated with a systemic process, and radical measures serve 
only to open up the lymphatics for further diffusion of the infec- 
tion. Pvoktanin seems to exert as favorable an influence over 



ABSCESS OF SEPTUM. 335 

this variety of ulceration as any drug. It may be applied in a 10 
to 20 per cent, solution, or in powdered form, 10 to 20 grains 
of pyoktanin to the ounce of stearate of zinc. Equally good 
results may be obtained by the dusting on of pure aristol, or 
aristol and stearate of zinc in equal parts. The surface should 
be carefully mopped and dried before the powder is applied. 

In the non-infected varieties of perforation I have obtained 
good results from the application of liquid papoid, also the glyc- 
erinated extract of suprarenal capsule. These solutions should 
be applied daily, and, if beneficial, will usually stop the contin- 
uance of ulceration in from 4 to 6 applications. 

5. EDEMA (SUBMUCOUS INFILTRATION). 

Edema in any portion of the mucous membrane of the septum 
may occur at any age. It may be due to external irritants sud- 
denly applied — for example, inhalations of irritating fumes, such 
as iodin, bromin, etc., or of hot vapors ; it may follow injuries not 
sufficient to fracture the cartilage or bone, and is also associated 
with perichondritis, there being marked edema over the area of 
inflammation. This is especially true in the specific inflammatory 
processes, or when the cartilage is involved after typhoid fever or 
other infectious fevers. The edema may be limited to one side of the 
septum, or both sides may be involved, more frequently the latter. 
Edema may also follow injuries involving the bony framework or 
operations on the septum. It may be associated with diseases of 
the teeth, or the inflammatory process may spread upward by 
contiguity of structure from the floor of the nose. It frequently 
follows the application of the galvanic cautery or escharotics. 
The edema will often disappear by absorption and require no 
treatment whatever. But if severe and obstructive, it may be 
relieved by puncture or scarification, or by the application of 
40 per cent, ichthyol in lanolin, or the application of 3 per cent, 
ehlorid of zinc, or sulphocarbolate of zinc, 10 grains to the ounce. 
The best method of treatment is puncture or scarification, which 
should be followed by the application of a 3 per cent, formalin 
solution, or, if this is painful, by the application of -^ of 1 per 
cent, formaldehyd solution, to each ounce of which is added 24 
grains of cocain. Equally good results may be obtained by the 
application of a 6 per cent, solution of suprarenal extract. 

6. ABSCESS. 

Acute Abscess. 

Etiology. — Acute abscess of the septum may be the result 
of trauma, either direct or following effusion of blood into the 
tissue as the result of a blow. It mav follow the infectious 



336 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

fevers, such as measles, scarlet fever, or typhoid fever. When 
due to injury, there is usually some external manifestation which 
gives a clue to its cause. There may be injury of the bony 
structure as well as of the cartilaginous portion. Abscess of the 
septum may also form in erysipelas, or may be associated with 
uric-acid, gouty, or rheumatic diathesis, which possibly explains 
some of the cases of acute abscess-formation from the so-called 
acute idiopathic perichondritis. Acute abscess of the septum may 
follow sudden acute inflammations of the nasal mucous membrane, 
as in acute coryza. It may be associated with purulent rhinitis 
in children, may occur in the scrofulous or rachitic diathesis, 
or may also be due to disease of the teeth, in which the infection 
reaches the septum by contiguity of structure. This is especially 
true of individuals with ill-formed superior maxillary bones, giv- 
ing a flat and narrow arch. 

Pathology. — The pathology of abscess of the septum is iden- 
tical with the pathology of abscess-formation in any other struct- 
ure. The cartilage is usually separated and the cavity formed 
between the two layers. There is a tendency to bulging or to 
spreading to the tip of the nose, which is the line of least resistance. 
There are present all the phenomena of acute inflammation going 
on to rapid termination, which in abscess-formation results as 
liquefaction-necrosis due to infection by the pus micro-organisms. 
Symptoms. — If due to trauma, there will be evidence of 
external injury, supported by the history. The mucous membrane 
on both sides of the septum will be intensely swollen and edema- 
tous, even to the extent of occluding both nostrils, but, as a rule, 
more marked on one side. The nose is swollen externally, red and 
inflamed. There is intense headache in the nasofrontal region ; 
the eyes are injected and the lids puffy. The pain in the nose is 
intense and of a throbbing, lancinating character, difficult to con- 
trol even with anodynes. There is general malaise, and often an 
associated rise of temperature. Usually, in from twenty-four to 
forty-eight hours, the swelling shows distinct pointing ; the dis- 
coloration becomes more marked and the pain less severe. The 
entire face may be swollen or the upper lip alone involved. The 
nose is excessively sensitive to the touch. As the abscess-forma- 
tion progresses, there will be noticed fluctuation on pressure, the 
cartilage distinctly yielding at its dependent portion. 

Diagnosis.— The diagnosis of acute abscess of the septum is, 
as a rule, clear ; the only condition permitting of confusion would 
be acute edema of the septum. This condition resembles acute 
abscess from a standpoint of swelling alone, with all the other 
symptoms less marked. 

Prognosis. — The prognosis of acute abscess of the septum is 
good, although in some cases, when the abscess is allowed to 
progress until spontaneous rupture occurs, there may be result- 



ABSCESS OF SEPTUM. 337 

ing deformity or perforation ; but if the condition is recognized 
early and free incision made, the prognosis is good. 

Treatment. — The treatment consists in early and free inci- 
sion of the cartilage from one side only. This incision should be 
made through the cartilage low down on the septum, so as to 
insure free drainage from the dependent portion of the abscess. 
There is a tendency of the cartilage to close after the incision, 
thereby interfering with drainage. This may be obviated by 
placing in the opening a small piece of gauze, or, if the cut be 
made obliquely to the perpendicular septum, this tendency to close 
can be markedly lessened. After the opening of the abscess, the 
cavity should be carefully washed out, first with an antiseptic 
alkaline solution, such as boric acid, or carbolic acid and water, 
followed by hydrogen peroxid and cinnamon water in equal parts. 
The cavity should then be flushed out with a 1 : 500 aqueous 
pyoktanin solution, the only objection to this being that it stains 
the tissues with which it comes in contact externally. This stain, 
however, can easily be removed by the use of dilute acid alcohol. 
I insist on early and free incision, since by this means any bad 
results, such as necrosis, ulceration, and deformity, can be obviated. 
Internal medication should consist in free purgation. If there 
is any existing rheumatic or gouty diathesis, the recurrence of 
abscess-formation may be lessened by the constitutional treatment 
of such condition. 

Chronic Abscess. 

Chronic abscess of the septum is a rare condition. As a rule, 
it is the result of involvement of the cartilages after typhoid fever 
or other specific fevers, although it may be due to syphilitic or tuber- 
culous necrosis, yet the latter conditions are more often associated 
with perforation. Chronic abscess usually involves the anterior 
portion of the cartilaginous septum. It is of slow progress, and 
the clinical phenomena are not marked. On examination, a fluct- 
uating tumor will be found involving the septum and slightly 
obstructing both nasal cavities. If it be of syphilitic or tuber- 
cular origin, the history of the case will greatly aid in the diag- 
nosis. In ulceration of the septum following typhoid fever, there 
may be no associated nasal conditions. 

Treatment. — The treatment should consist in free incision of 
the cartilage on one side only, thorough and complete curetment 
of the pyogenic or limiting membrane, and thorough flushing with 
an antiseptic solution. The cavity should be packed with iodo- 
form gauze. Following chronic abscess there is a marked ten- 
dency to perforation of the septum. The individual's general 
health should be improved by the administration of systemic 
tonics. 

22 



338 DISEASES OF THE ANTERIOR NASAL CAVITIES. 



7. CORRECTION OF EXTERNAL NASAL DEFORMITIES. 

Depression of the cartilage gives rise to innumerable varieties 
of external deformity. The cause of the depression may be trau- 
matism or abscess of the septum, which gives rise to the deform- 
ity known as pug nose. The condition may be associated with 
ulceration and perforation of the septum, as is seen in syphilis or 
tuberculosis, and in scrofulous, strumous, or rachitic diatheses. 
Accordingly, depression of the cartilage may occur without loss 
of structure, or it may be due to partial destruction or entire per- 
foration. Where perforation has taken place, the depression is 
usually flat, and the soft structures seem to spread out on the face. 





Fig. 124.— Bones and cartilages of the external nose. A, Side view : a, Cartilage of 
septum; b, upper and (c) lower lateral cartilages ; d, sesamoid cartilages; e, cellular tissue; 
/, nasal bone ; g, nasal process of superior maxillary bone. B, View from below : a, Lower 
lateral cartilage ; 6, sesamoid cartilages ; c, cellular tissue. (Gleason.) 



The lateral diameter of the nasal orifice is increased, while the 
perpendicular dimension is markedly diminished. Depression 
from injury or septal abscess gives the peculiar sunken appearance 
on the top of the nose, with the odd up-tilted tip. For the cor- 
rection of these various deformities it is impossible to outline a 
treatment that would apply to every case. However, in the par- 
affin (Gersuny's) method, as given on page 154, we have the most 
satisfactory procedure. For several years the method of correct- 
ing certain deformities, such as saddle-back nose, by the injection 
of paraffin was much in vogue. In my previous editions I called 
attention to the method and also to the danger attending its use. 
The great difficulty with this method is that, although the paraffin 
may be successfully introduced into the tissue, after from one to 
three years it begins to act as a foreign body, and over the area 
of the injection the tissue becomes inflamed and in some cases 
has broken down and caused ulceration. So far no successful 



CORRECTION OF EXTERNAL NASAL DEFORMITIES. 339 

method of removing the paraffin has been devised. It is well, 
then, if one resorts to this method of correcting deformities, that 
he acquaint the patient thoroughly with the possible result (see 
page 154). 

The best method for the correction of the deformity com- 
monly known as saddle-back nose is that suggested by Dr. J. A. 
White, of Richmond, and is as follows : 

" Where there is any depression of the nasal bones and flatten- 
ing at the bridge it is well to correct this before attempting to 
elevate the depression in the soft parts. 

" A glance at Fig. 124 will show that the nasal bones rest upon 
the processes of the superior maxillary, and when the nasal bones 
are fractured or driven in these processes, which often partici- 




Fig. 12o.— Osseous and cartilaginous septum of the nose: 1, Triangular cartilage of the 
septum; 2, median plate of the lower lateral cartilage, sometimes called columnar carti- 
lage and cartilage of the aperture ; 3, cartilage of Jacobson : 4, supravomerine cartilage 
sometimes present ; 5, vomer ; 6, perpendicular plate of ethmoid ; 7, ethmovomerine suture ; 
8, sphenoidal sinus ; 9, nasal bone ; 10, palate bone. (Arnold.) 

pate in the pathological change, are separated more widely than 
they should be. The best way, therefore, to elevate the osseous 
structure is to break this process loose from its attachments with a 
mallet and the flat side of a chisel covered with rubber, and then 
loosen the nasal bones by means of strong forceps, one blade 
inside and one out, the inside blade being covered with rubber. 
This will make the osseous framework movable with the fingers. 
They can then be moulded into shape and packed up from the 
inside into a vulcanite mould, which has been made over a 
nose of good contour, which mould is held in place by straps. It 



340 DISEASES OF THE ANTERIOR NASAL CA VITIES. 



will take at least a month for the parts to adjust themselves, and, 
when adjusted, will accentuate still more the depression of the 
cartilaginous and soft parts. Fig. 124 also shows the relation of 
these parts to the osseous structure and to each other. 

" The elevation of the latter is accomplished as follows : First, 
the cuticle and subcutaneous tissues at the point of depression are 
loosened from the septum subcutaneously, so that a probe can be 
passed from one nostril to the other over the triangular carti- 
lage which is shown in Fig. 1 25, and is usually depressed, twisted, 
and driven down over the vomer. Then the inferior lateral carti- 
lage, which is part of the framework of the ala of the nose, is split 
from without inward and up to its connection with the septum 
cartilage (see Fig. 126). This is done on each side, leaving a flap 
hanging in either nostril attached to the angle formed by the 
septum cartilage and the cartilages of the ala. A thread armed 

with two needles is passed 
through the lower end of 
the flap (see Fig. 126). The 
needles are then passed up 





9MS 



Fig. 126. 




through the gap made between the septum cartilage and the over- 
lying soft parts when these latter were separated, under the skin 
and over the cartilage, and then through the superior lateral car- 
tilage and skin of the opposite side (see Fig. 126). By tying the 
two ends of the thread together over a roll of tape the flap is 
pulled up into the gap between the skin and cartilage and held in 
place (Fig. 127). 

" When the two flaps are tied into position the raw surfaces are 
brought into apposition and the flaps completely fill up the gap 
between the skin and cartilage and make an elevation where pre- 
viously there was a depression. 



CORRECTION OF EXTERNAL NASAL DEFORMITIES. 341 

" In the healing process this slight elevation gradually con- 
tracts, so that the profile of the nose becomes practically a straight 
line. 

" Of course, the amount of elevation depends upon the amount 
of tissue or the size of the flap made, and some judgment has to 
be used in making the flap." 

" I have attempted an operation several times very similar to 
this without passing the stitches through the lateral cartilage 
and skin, pinning the flaps into position on the inside, but with 
very poor success. Putting in the stitches as above described pre- 
vents the flaps from becoming displaced and holds them firmly 
until cicatrization takes place. The healing is rapid and the 
stitches leave no noticeable scar." 

In correcting deformity due to abscess of the septum, an in- 
genious and common-sense method has been suggested by Roe. 
This consists in strengthening the septum by tissue brought in 
from the sides. As is pointed out by him, there is usually marked 
thickening of the dorsum. This thickened tissue is incised 
through to the under side of the skin on both sides, a short dis- 
tance from the septum, at a point where it thins into the ala 
of the nose. The skin is then raised from the dorsum and the 
flaps turned upward and held in place by perforated ivory splints, 
these being retained in position by means of sutures passed directly 
through the flaps and tied so as to hold them in place, care 
being taken not to exert sufficient pressure to produce strangula- 
tion of the parts. In order to elevate the arch of the nose and 
increase the solidity of the septum, each side of the lower portion 
of the septum and floor of the nose is scarified and the anterior 
portion of the septum divided, leaving the front portion of the 
skin intact. Thick flaps of tissue are then cut from the floor of 
the nostril opposite the portion of the septum which is to be ren- 
dered more rigid. These are held in position as given above, 
and also connected to the cut portion of the septum by fine sutures. 
This method, as well as any other, will have to be modified to suit 
individual cases. 

William W. Garter's Bridge-splint Operation. — Carter points 
out that it is mechanically impossible for any form of splint, pack- 
ing, or intranasal appliance to raise or even to support a depressed 
bridge. According to measurements, which he made on a large 
number of skulls, he found the roof of the nose, if prolonged 
downward and forward, would meet the level of the floor at an 
angle of 70 degrees, while the vertical diameter of the nasal orifice 
is only three-eighths of the distance from the center of the nasal 
bone to the floor of the nose ; and, therefore, that any intranasal 
appliance, depending on the floor for support, would immediately 
be propelled toward the choanae by the inclination of the dorsal 
plane. 



342 



NEOPLASMS OF THE RESPIRATORY TRACT. 



Carter has devised a nasal splint, as seen in Fig. 128, which 
applies a combination of these two forces, one acting from within 
the nose at its apex and the other from the outside at the base. 

The splint consists of a fenestrated steel bridge, the wings of 
which are connected by a hinge, and the distance to which they 
can be separated is regulated by a thumb- 
screw. The edges of the wings are padded 
with rubber, and the small holes near the 
edges permit of gauze padding being stitched 
on. The second part of the instrument con- 
sists of two small hard-rubber splints, perfor- 
ated by four small holes. 

Carter describes the application of the ap- 
paratus as follows : " Assuming that there is a 
recently depressed fracture, or, in the case of 
an old deformity, that the tissues have been 
thoroughly mobilized by a previous operation, 
to be described later, No. 14 iron-dyed silk 
is passed through one of the holes in the hard-rubber splint and 
knotted; the other end is threaded into a large curved needle; 
this is passed from within the nose, through the cartilaginous 
dorsum just below its attachment to the nasal bones. This 




Fig. 128.— Bridge and 
intranasal splint for cor- 
recting depressed deform- 
ities of the nose. 




Fig. 129.— Sectional view of splint and bridge in place (Carter). 



process is repeated on the opposite side. The bridge is then 
applied and the wings adjusted with the thumb-screw to give the 
proper support to the base of the nasal triangle. The sutures are 
then i an through the fenestra? in the bridge, corresponding verti- 



CORRECTION OF EXTERNAL NASAL DEFORMITIES. 343 



I 



cally to their exit from the nose and drawn tight enough to lift 
the dorsum into its proper position. The sutures are then tied 
together over the hinge. There should be only sufficient tension 
to support the bridge. The dia- 
gram (Fig. 129) shows the bridge f^W 
and splint in position. The splint ^ /J ~ 
rests partly under the nasal bone 
and partly under the cartilaginous 
dorsum. The resultant pressure 
and counter-pressure keep the ap- 
paratus in position. It should be 
worn for ten days or two weeks. 
" In old traumatic deform- 
ities it is necessary to mobilize ^g. 13q.-IUustrating the mechanics of the 
, , , ,, . , . intranasal splint and bridge. 

thoroughly all the tissues, and, in 

addition, if the nose is very flat and there has been loss of tissue, it 
is frequently necessary to utilize a portion of the nasal processes of 
the superior maxilla. A narrow chisel of special design (Fig. 131) 




ail 



Fig. 131.— Carter's chisel for the nasal processes of the superior maxillae. 

is placed against the anterior edge of the nasal process of the superior 
maxilla and driven upward; the progress of the chisel can be watched 




Fig. 132.— Adams' forceps. 



by placing the finger on the side of the nose, care being taken not to 
go through the skin. When the chisel has been fairly engaged, the 




Fig. 133.— Carter's chisel-forceps for cutting through the nasal bones. 

strip of bone can be broken off by turning the chisel from side to side. 
There is little or no danger of splitting the bone into the lachrymal 



344 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

canal, for, as shown by Berens, the grain of the bone runs away 
from the canal. I found by measurements made on a large number 
of skulls that the lachrymal canal is about five-eighths of an inch 
behind the anterior border of the nasal process of the superior 
maxilla. This places it beyond the danger zone in the normal 
skull. 

" Further mobilization of the tissues is accomplished with the 
Adams forceps (Fig. 132) by placing one blade inside the nose and 




Fig. 134.— Bone transplantation for nasal deformity. The central figure shows method 
of elevating skin and subcutaneous tissues ; the insert figure shows the bone in place 
(Carter). 



the other, covered with rubber tubing, on the outside. The sep- 
tum is then grasped between the blades and mobilized. A specially 
devised chisel forceps (Fig. 133) I have found very useful in cut- 
ting through the nasal bones near their articulation with the frontal 
bone. The chisel blade is introduced into the nose up to the de- 
sired point, the outside flat blade being covered with rubber tubing 
and the set-screw carefully regulated so that the chisel will not 
cut through the skin. In cases in which the septum is badly de- 
formed, a submucous operation should be done a day or two before 



SYPHILIS. 



345 



the bridge splint procedure. When the nose is very flat and the 
shortened septum is holding down the dorsum, I make an oblique 
incision through the septum, beginning at a lower level and em-erg- 
ing in the opposite nasal chamber near its roof. This permits the 
upper segment to be raised without leaving a perforation, and 
is a substitute for the sliding flap operation formerly suggested 
by me. 

" Where there is a step-like deformity caused by luxation of 
the lateral cartilages at the point of attachment to the ends of the 
nasal bones, before applying the bridge, I make an incision from 




Fig. 135.— X-ray plate showing transplanted bone in position (Carter). 



within through both lateral cartilages and the septal cartilage along 
the line of depression with a Myles rectangular septal knife. This 
enables me to lift the cartilaginous portion of the dorsum into line 
with the bony portion of the bridge." 

William W. Carter's Bone Transplantation Operation. — In the 
correction of deformities by the transplantation of bone, the method 
used by Carter seems to be a successful one, and is as follows : 

" After preparing the field of operation, observing the strictest 
antiseptic and aseptic precautions, a curvilinear incision, convexity 
downward, is made from the inner extremity of one eyebrow to 



346 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

that of the other. This cut extends to the periosteum, but not 
through it. A special sharp elevator is introduced through this 
incision and the skin and subcutaneous tissue elevated over the 
dorsum and sides of the nose, and in some instances for a consid- 
erable distance beyond the nose under the cheeks. The semilunar 
flap made by the first incision is then lifted up and a short trans- 
verse cut made through the periosteum over the nasofrontal proc- 
ess. The periosteum above this incision is elevated for about ^ 
inch. This wound is covered with sterile gauze, and we proceed 
to the second step in the operation, the resection of the rib. A 
straight incision 4 inches long, including the periosteum, is 
made directly over the ninth rib. The rib is then shelled from its 
periosteum by means of a curved elevator and 2 inches of the 
bone removed with the costotome. This section of the rib is then 
split in its transverse diameter, and from one of the halves (usually 
the outer) all of the medullary tissue is scraped with a sharp 
curette. This piece is shaped to suit the deformity, and in the 
following manner is slipped into the place previously prepared for 
it in the nose. The semilunar skin flap is held upward out of the 
way with a tenaculum, the strip of bone is introduced, and the end 
is pushed nearly to the tip of the nose. The upper end is passed 
through the split in the periosteum and anchored in contact with 
the frontal bone. We now observe whether or not the deformity 
has been corrected ; if it has not, one or two strips of bone are 
superimposed on the first. 

" The wound is closed with horse-hair sutures and a sterile 
dressing applied. If all is well this dressing is not disturbed 
until the seventh day, when the sutures are removed." 

8. SYPHILIS, 

Tertiary syphilis of the upper respiratory tract is principally 
manifested in the mucous membrane or in the bony or cartilagin- 
ous framework, the gummatous change taking place in the sub- 
mucosa of the mucous membrane. The gummata formed in the 
nose, mouth, and pharynx vary greatly in size. The nose is 
the common site and is observed in the very late stages of the 
disease, usually manifesting itself in some ten to twenty years 
after the primary infection. This is especially true where there 
has been a mild infection and the lesion is really a latent one. 
Fig. 136 illustrates a gummatous condition involving the sep- 
tum and bony framework, in which the inflammatory area sur- 
rounding this breaking down gumma accounts for the swelling 
and discoloration. The gummata may be limited to the septum or 
it may involve adjacent structures. Involving the septum and 
breaking down with destruction of tissue, we have the typical 
saddle-back or pack-saddle nose. 




\ 



V 



Fig. 136.— Syphilis involving the cartilage and bones of the nose. 



TUMORS OF THE SEPTUM. 347 

9. TUMORS. 

The bony growths involving the septum, including osteoma, 
chondroma, exostoses, ecchondroses, spurs, etc., have been fully 
considered under Tumors. 

Hematoma of the Septum (Blood-cyst). — Hematoma or 
blood-tumor of the septum is not, in reality, a new growth, but 
is a sudden effusion of blood into the submucosa as the result of 
contusion. It may occur on one or both sides of the bone or 
cartilage. This extravasation of blood may be associated with 
fracture of the bone or cartilage. There are always a history of 
injury of sudden onset and the secondary inflammatory phe- 
nomena. The extravasation may become encysted or, owing to the 
secondary inflammatory phenomena, may break down and suppu- 
rate. Small hematomata may occur from rhexis, as is seen in the 
eruptive fevers, or associated with uric acid or rheumatic diathe- 
sis, or even occasionally after violent exercise. These undergo 
absorption and require no special treatment. However, in exten- 
sive extravasation it is usually necessary to puncture the tumor 
under antiseptic precautions. The nostril should then be 
packed with antiseptic gauze thoroughly impregnated with boric 
acid. The packing should be so placed as to exert pressure at 
the site of the hematoma, and should be changed at least every 
twenty-four hours. Care should be exercised in the packing of 
the nostrils, so that pressure sufficient to cause ulceration is not 
exerted. 

Angiomyxomata. — The angiomyxomata, or bleeding polyp, 
is commonly seen on the septum, although it is a rare condition 
and but few cases have been reported. It is possible that it is 
nothing more than a telangiectasis with some myxomatous degen- 
eration. There is a marked tendency to recurrence after removal, 
no matter what method is followed, whether by actual cautery or 
by snare, or removal by strangulation or cutting instrument. 

Angioma of the Nasal Septum. — Angiomata, telangiecta- 
sis, bleeding polyps, in fact all vascular tumors of the nasal 
septum, are more one of degree than variety, the different terms 
being based on the degree of alteration in the blood-vessels, the 
extent of involvement, and the size of the tumor. 



CHAPTER XIII. 

DISEASES OF THE ANTERIOR NASAL CAVITIES. 
DISEASES OF THE ACCESSORY SINUSES. 

Diseases of the Maxillary Sinus. d. Specific Inflammations. 

a. Catarrhal Inflammations. e. Acute Infectious Diseases. 

1. Acute. 2. Chronic. /. Emphysema. 

b. Ozena. g. Foreign Bodies. 

c. Empyema. h. Mucocele. 

1. Acute Purulent Inflammation. i. Tumors. 

2. Chronic Purulent Inflammation. j. Phlegmonous Inflammation. 

3. Confined Suppuration. 

But little is absolutely known as to the physiological function of 
the accessory sinuses, and to this fact, perhaps, is in part due the too 
frequent errors in diagnosis which their pathological processes in- 
volve. Cryer, Holmes, and others have done much toward clearing 
up the relation and topography of the cavities. The late development 
of the sinuses is possibly a second factor ; while yet a third ele- 
ment may be found in the tendency of the practitioner to assign to 
a coexistent nasal lesion all the symptoms observed in a given 
case, though their main body, perhaps even their exciting cause, 
may be traced to the manifestations of a diseased sinus. It is 
undoubtedly the case that many of the nasal lesions which the 
specialist is called upon to treat, and which refuse to yield to treat- 
ment, however proper and correct its rationale, will upon careful 
search be found to be inflamed and aggravated by some active 
pathological process in the accessory sinuses. So that here, as in 
all branches of medicine, the necessity of a thorough painstaking 
search to elicit genetic factors is a prime essential to successful 
treatment. In diseases of the accessory sinuses, especially the 
frontal, sphenoidal, and ethmoidal — rarely in the maxillary sinuses 
— on account of the involvement of the brain structure through 
pressure and septic sinus thrombosis, we frequently have a chain 
of mental symptoms, depending, of course, entirely on the extent 
of and the structures involved. 

Pathological alterations of the structures of the accessory 
sinuses may be divided into two classes, according to the tissues 
involved : First, we have the changes affecting the mucous mem- 
brane alone, and, second, those involving the deeper structures or 
bony framework. 

348 



DISEASES OF THE ACCESSORY SINUSES. 349 

The accessory sinuses are, for all practical purposes, closed cav- 
ities, and while the mucous membrane lining these cavities is sim- 
ilar to that of the upper respiratory tract, yet the glandular 
elements and the terminal nerve filaments are not nearly so 
numerous as in the exposed mucous membrane. The epithelial 
layer of the membrane is also much thinner and the cells resemble 
more those of the endothelial type, and the mucous membrane, 
therefore, has less resisting power. 

Inflammatory processes involving this structure do not differ 
from those occurring in any other mucous membrane, with the 
exception that they pass through the various stages with greater 
rapidity, so that the difference is merely one of degree or inten- 
sity. Any infection of the accessory cavities would necessarily 
be preceded by or associated with some inflammatory process, 
which process involves the opening of the sinus and thus converts 
it into a closed cavity, causing retention of the infectious material. 
This, in turn, intensifies the already existing inflammation and 
produces rapid changes in the mucous membrane, which, if 
drainage is not established, may lead to total destruction of the 
membrane and necrosis of the underlying bony structure. If the 
severity of the inflammatory process is not sufficient to cause 
destruction of the mucous membrane and denudation of the 
bony walls of the cavity, a fibroid formation within the basement 
membrane may take place, or, in other words, the physiological 
function is interfered with, resulting in permanent pathological 
alteration. 

"When there has been a destruction of the mucous membrane 
lining these cavities, it is not likely to be regenerated, owing to 
the fact that the blood- supply to the submucosa is not so profuse 
as in the respiratory tract, and also that the genetic layer of 
the epithelial surface is less substantial and less capable of re- 
production. 

I have observed in a few cases, where the accessory cavities 
have been freely opened, that the pathological alteration accom- 
panying the process had not produced a permanent lesion, and 
when the cause was removed the mucous membrane returned to the 
normal, but the practically closed cavity had been converted into a 
wide-opeu one and the patient suffered from symptoms almost 
identical with those of confined suppuration of these cavities, such 
as faceache, the neuralgia, sense of pressure, the general dis- 
comfort with, of course, no rise in temperature. One of these 
cases in particular I have watched for the past three years. This 
individual had six accessory cavities opened and the delicate, 
sensitive mucous membrane, which was not physiologically in- 
tended to come in contact with the air and dust, was particularly 
susceptible to the slightest climatic changes. It was found by 
placing the patient in a room with an even temperature that almost 



350 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

instant relief was obtained, and I believe that all the symptoms 
were produced by the use or misuse of these sinuses, as they are 
not intended as respiratory cavities. By stimulation following the 
use of these cavities, and the increase in the blood-supply of the 
exposed mucous membrane as a result of this stimulation, the 
membrane has gradually thickened and, in other words, has 
physiologically changed, and while it may be somewhat of a patho- 
logical process, it has produced a physiological result and lessened 
the sensitiveness of these cavities and developed the membrane. 
During the past winter the patient has had practically no 
symptoms of any involvement of these sinuses. 

As a rule, confined suppuration within the accessory cavities 
shows irregular systemic symptoms, unless there is a point where 
the physiological wall of the closed cavity has broken down, and 
rapid general septic infection takes place, when the clinical phe- 
nomena are pronounced. In other words, infection of the acces- 
sory cavities amounts to a walled-in process, and it is only when 
necrosis takes place that systemic infection occurs. 

Infection of the accessory cavities is usually secondary to 
or associated with lesions of the adjacent structures, and in a large 
majority of cases the etiological factor may be found in the nasal 
cavity. The continuation of the pathological process within the 
accessory cavity will depend entirely upon the pre-existing con- 
dition within the nasal cavity. While the pathological altera- 
tion occurring within the cavity is a definite and distinct one, the 
arrest of that process is subject to the same general law which is 
the basis of all surgical treatment, namely, the removal of the 
cause. If the infection is due to the pneumococcus, streptococcus, 
or bacillus of influenza, there is a marked tendency to bony 
necrosis. 

A point of considerable importance as regards the invasion of 
surrounding structures by the pathological process, as well as 
accounting for the varied symptoms produced, is the size and 
shape of the cavity and the variations in the thickness of its 
walls. For example, a frontal sinus with thin walls may result in 
perforation and involvement of the brain-cavity. Dural and sub- 
dural abscesses frequently follow pathological changes within the 
frontal sinus. Again, in the case of the antrum of Highmore, 
where the superior wall is very thin you will have marked eye- 
symptoms, while in another case with a thick bony wall the eye- 
symptoms will be entirely absent. The spreading of an infectious 
process from one accessory cavity to another is usually explained 
by some abnormal communication. 

Irregularities and abnormalities as to the formation of the 
accessory cavities, the antrum, etc., may explain many of the 
peculiar and unique cases often reported. It has been shown by 
sections of the skull, with a view to demonstration of the relation 



DISEASES OF THE ACCESSORY SINUSES. 351 

of the accessory cavities to the nasal chamber, and to each other, 
that almost any size or shape of cavity or thickness of bone is 
possible, the antrum cavities varying in size from a little larger 
than a pea to three times the usual size and extending under the 
floor of the nose. 

In cases associated with nasal lesions it is quite likely that the 
chronic inflammatory process set up in the floor of the nose may 
interfere with the nervous and vascular supply of the tooth 
directly under it, causing a trophic function with devitalization. 

Recent clinical observations have clearly proven that many 
lesions of the head and face suggesting antral disease, the cause of 
which has been more or less obscure, have their origin in abnormal 
or pathological conditions of the dental organs, such as teeth irrupted 
into the nose or antrum, or diseased teeth affecting either cavity. 
Irregularities in the formation of the accessory cavities will bring 
about irregularity in the upper arch and predispose to dental 
lesions as well as nasal disease. This is not only caused by nasal 
obstruction and improper passage of air, but also by poor nutri- 
tion, as the current of air passing to and fro in the nostril 
stimulates circulation in the nasal mucous membrane. 

One-half of the arc of the orbit is taken up by the accessory 
cavities and many eye-symptoms are associated with or follow 
lesions of these cavities. Orbital abscess is secondary to disease of 
the sinuses, displacement of the globe maybe occasioned by encroach- 
ment on the orbit by a distended sinus, and blindness may result 
from an involvement of the chiasm through the roof of the cavity 
or by an implication of the optic nerve as it passes through its fora- 
men, in the sphenoid, as a consequence of inflammation in the cells 
within that bone. A general orbital cellulitis may be occasioned 
by an acute perforation of any sinus. Edema of the lids is one of 
the most significant symptoms of disease of the accessory sinuses, 
and is to be distinguished from the inflammatory swelling and 
thickness of the lid which results from cellulitis, as it is entirely 
non-inflammatory in origin. Paresis, and even paralysis, of 
one or more of the eye-muscles may occur as a consequence of 
sinusitis. 

The sphenoid and ethmoid cavities being in reality nothing more 
than honeycomb cells, an infectious pathological process occurring 
within these cavities is extremely likely to produce bony necrosis 
if the infectious process is of sufficient severity to cause necrosis 
of the mucous membrane. The delicate bony structure is depend- 
ent upon its blood-supply coming from the mucous membrane ; 
this is not true of the frontal sinus and antral cavity. In the 
latter cavities the bone may be denuded of the mucous membrane 
with no necrosis of the bony structure. In other words, bony 
necrosis is more likely to occur within the ethmoid and sphenoid 
cavities. The pathological changes in the sphenoid and ethmoid 



352 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

cavities, following infections, even after the cavities are opened, are 
more likely to continue than in the frontal or antral cavity. In 
the latter better drainage can be established and the infectious 
material can be more thoroughly eradicated ; in other words, more 
complete surgical interference can be employed in the antral and 
frontal cavities than in the sphenoidal and ethmoidal. Meningitis 
and sinus involvement are likely to follow frontal, ethmoidal, and 
sphenoidal sinusitis. Occasionally cases are seen in which infec- 
tions of these cavities produce practically no symptoms. 

I recall a case which came under my observation in 1899, and 
which I reported at that time. The patient, a woman of sixty 
years, after being indisposed for a few days experienced a sensa- 
tion of fulness on the left side of the nose, opposite the inner 
angle of the orbit. There was no pain, only a sense of uncom- 
fortable fulness. There was a considerable discharge from the 
nose of a thin, watery secretion ; the character of the secretion 
varied slightly in the morning, when it was thick and tenacious. 
There was a great deal of swelling over the face, especially 
between the eyes, which gave a peculiar facial expression, as 
though the eyes were wide set. There was not much tenderness 
on pressure over the swollen area. There was, however, some 
soreness at the inner angle of the eye over the region of the 
ethmoid cells. During the month of February, the symptoms 
first being noticed in January, the patient had quite a severe 
attack of epidemic influenza or la grippe. She was confined to 
her house about a month. During this attack there was practically 
no change in the condition of the forehead. The swelling re- 
mained about the same, and there was possibly a slight increase in 
the clinical phenomena. However, after the patient was able to 
be up, which was about the first of April, the swelling became 
more marked, especially under the eyes and on the left side in the 
region of the nasion, about an inch and a half above the base 
of the nose. There was considerable discharge from the nostril, 
possibly more pus-like, although nothing more than would be from 
an ordinary continued rhinitis. There was more soreness at this 
time, although not painful ; the patient complained of malaise 
and a peculiar sick feeling ; there was marked general debility, 
and the patient seemed to be failing very fast in general health. 
Prior to this attack she had been in the best of health — had never 
up to that time even suffered from a headache. During the month 
of May the patient developed marked swelling in the limbs — 
in fact all the symptoms were aggravated ; there were sore spots 
here and there over the limbs, with some petechia? and slight in- 
flammation. There was constant shifting of these spots. There 
were pronounced aching about the joints and symptoms of a 
decided rheumatic condition or gouty diathesis. There was very 
little change in the swelling of the face ; if any difference, it was 



DISEASES OF THE ACCESSORY SIX USES. 353 

more marked. At no time was there any acute pain, the promi- 
nent symptom being the edematous condition. The patient had 
lost over thirty pounds in flesh and was quite weak and debili- 
tated. The last of June she consulted me, when I found the fol- 
lowing conditions present : 

The tissue on the forehead was so swollen that it hung 
down over both supra-orbital ridges, with marked swelling under 
both eyes, especially the left, giving the patient's face a most 
peculiar appearance. In the median line, about an inch above the 
line of the supra-orbital ridge, was a marked projection, almost 
tumor-like, with a distinct redness and somewhat pitted in the 
center, with a small spot on which there was some dried secretion. 
On examination of the nose I found practically no discharge on 
the right side, only a slightly catarrhal inflammation ; the left side 
was markedly edematous ; the mucous membrane was covered 
with a thin, glairy discharge with tendency to accumulation. The 
upper part of the nostril was so edematous and swollen as to com- 
pletely occlude the cavity, This tissue was depleted by the local 
use of an 8 per cent, solution of cocain, and after retraction of the 
tissue I could elicit no discharge from the openings of any of the 
accessory cavities. After the use of the cocain there was perfect 
breathing through the nostril. There was practically no patho- 
logical alteration within the nasal structure, the septum being 
almost straight, and there was enlargement of the turbinal bodies 
or lining membrane. Transillumination was resorted to, from a 
diagnostic standpoint, and the antra showed a perfectly clear 
outline. I was unable to make any satisfactory illumination of the 
frontal sinus or of the upper portion of the nose ; however, I 
believed I had to deal with a confined suppuration in the left 
frontal sinus or possibly involving both sinuses. In passing a 
probe over the skin at the point bulging with pitting, on removal 
of the slight crust formation I found that the necrotic tissue 
had given way and the abscess was already opened externally. On 
pressure, and by the patient leaning forward, there was a discharge 
of foul-smelling, thick pus, and by slight digital examination I 
found that there was a necrotic area, almost circular, about three- 
fourths of an inch in diameter. I then passed a probe into the 
opening, and, allowing it to follow the line of least resistance, it 
passed down without any force whatever until it lodged against a 
soft material. By tapping it gently I felt that it was necrotic 
bone. With a little pressure the probe passed through into the 
nasal-cavity. At the same time light was reflected into the nostril, 
and the point of the probe could be seen on the septum side of the 
middle turbinal, about the middle third. I then had free drain- 
age. After the discharge of pus the sense of fulness at the 
inner angle of the orbit, which had continued from the first. 
entirely disappeared. The cavity was flushed out with warm 

23 



354 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

boric-acid solution followed by hydrogen peroxid, cinnamon water, 
and aqueous extract of hamamelis, equal parts. Within forty- 
eight hours the swelling had entirely disappeared from the face. 
The time from the spontaneous opening of the abscess until the 
complete closure of the wound was about two months. Occasion- 
ally the external opening would become occluded with dried secre- 
tion with slight return of the facial swelling; on re-establish- 
ment of the drainage this quickly disappeared. The patient's 
general health was improved by internal medication. Urinary 
examination showed no structural lesion of the kidney, but some 
leakage of serum albumin, possibly from the relaxed blood-vessels. 

From a general pathological standpoint we should remember 
that the accessory cavities are truly such and that they are not 
independent cavities ; that they are accessory cavities to what ? To 
the nasal respiratory tract. Hence, the origin of many pathological 
lesions is the nasal cavity. We must remember, also, that these 
accessory cavities are dependent upon adjacent structures for 
nutrition. Also, when infected, you are dealing with a closed 
cavity, but not a cavity of new formation, hence the pathological 
alteration is not subject to the same law as that of a cavity of new 
formation. 

Lesions of the accessory cavities may involve the eye and 
the order of involvement is usually the maxillary sinus, frontal 
sinus, ethmoidal sinus, and sphenoidal. One case which came 
under my notice at my clinic at the Jefferson Medical College 
Hospital was a man, 24 years of age, who had involvement of the 
maxillary and ethmoidal sinuses, in which there was confined fluid 
in these sinuses and a communication had been established be- 
tween the ethmoidal and antral cavities. The cavity was partly 
filled with granulation and polypoid structure and the pressure 
was due to these masses, plus confined fluid. The pressure had 
become so great as to cause displacement of the bony structure, 
and on account of the distention upward on the inferior orbital 
plate the eyeball was shoved forward, causing double vision and 
excessive pain. 

The neuralgic pains associated with lesions of the accessory 
sinuses have been referred to under Migraine, but too much 
importance cannot be attached to these cavities and their relation 
to headache and neuralgia and curious eye-symptoms. Figs. 137, 
138, 139, and 140 illustrate various normal and pathological con- 
ditions of the various sinuses. The foot-notes explain each plate. 
It is the duty of the rhinologist and the ophthalmologist to look 
carefully into the history of the patient as to whether there was 
any previous history or associated history of epidemic influenza, 
and whether there is any pathological alteration of these accessory 
cavities. It has been my experience that many cases of curious 
and illy-defined neuralgia about the head and face have been 



DISEASES OF THE ACCESSORY SINUSES. 355 



/ 





Fig. 137.— 1, Absence of frontal sinuses ; 2, ethmoid cells, normal ; 3, small antrii High- 
more ; 4, enlarged turbinate bones. 




Fig. 138. — 1, Right frontal sinus, large normal; 2, left frontal sinus, considerably 
smaller ; 3, ethmoid cells, normal ; 4, right antrum of Highmore, normal ; 5, left antrum 
of Highmore, thickening of mucous membrane. 



356 DISEASES OF THE ANTERIOR NASAL CAVITIES 




Fig. 139.— 1, Large multicellular frontal sinus, not diseased : 2, empyema of right antrum 
of Highmore ; 3, normal left antrum of Highmore. 



' ■■. ■ ■ ■■ . ^ . ■ : ■■■■;■ : 







' 



Fig. 140.— 1, Empyema of right frontal sinus ; 2, empyema of right ethmoid cells ; 3, em- 
pyema of right antrum of Highmore, opposite side normal. 



DISEASES OF THE ACCESSORY SINUSES. 357 

entirely cured when attention has been directed toward the 
accessory cavities. 

Even increased hyperemia of the mucous membrane of these 
cavities will cause headache. 

Under the name of Sphenopalatine Ganglia Neuralgia, Dr. 
Sluder describes a neuralgic picture consisting of pain in the root 
of the nose and in and about the eye, in the upper jaw and teeth 
(sometimes lower jaw and teeth), extending backward under the 
zygoma to the ear, frequently making earache and pain in the 
mastoid ; but severest often at a point 5 cm. back of the mastoid ; 
extending thence to the occiput, neck, shoulder-blade, shoulder, 
breast, and, when severe, to the arm, forearm, hand, and fingers ; 
with sometimes a sense of sore throat on that side. Mild cases 
manifest a sense of tension in the face and stiffness or " rheuma- 
tism " in the shoulders. It may appear as constant pain with ex- 
acerbations, or it may stop and reappear cyclically as a migraine ; 
or it may stop and reappear with stabbing sharpness, as a 
tic. Involvement of the sphenopalatine ganglion he believes 
is due in many cases to the extension of a local inflammation 
affecting the post-ethmoidal -sphenoidal cells. or from the membrane 
of the nose. In other cases it has its origin in a general systemic 
toxic condition. In making a differential diagnosis he points out 
that : First, cocainization of the sphenopalatine ganglion stops the 
pain of a lesion in the ganglion proper ; second, it does not in any 
degree stop the pain created by a more central lesion of the nerve- 
trunks secondary to sphenoidal inflammation ; third, on the other 
hand, intrasphenoidal application of pain-reducing remedies, such 
as cocain, will, under these conditions, stop the pain — that is, a 
local anesthetic applied central to the ganglion is effective. In 
addition to these points of difference there is often a congestion at 
the sight of the sphenopalatine foramen when the sphenopalatine 
ganglion is the starting-point for the neuralgia. This is more 
particularly true for the cases of inflammatory origin. Cases of 
toxic origin usually show no change in the nose. 

In the treatment of this condition, he finds that cases of a 
milder nature are relieved by application over the sight of the 
sphenopalatine foramen of different remedies — 2 per cent, solution 
of silver nitrate, 0.4 per cent, solution gaseous formaldehyd, or 
0.5 per cent, phenol with 0.1 per cent, iodin as a wash. In the 
more severe and stubborn cases he injects into the sphenopalatine 
ganglion 0.5 c.c. of a 5 per cent, solution of phenol in 95 per cent. 
alcohol. For this purpose a syringe with a straight needle is used. 
The needle is passed backward over the lower turbinate and under 
the middle until its tip reaches a point 2 mm. anterior to the pos- 
terior end of the latter. If now the point of the needle be directed 
slightly outward and forced through the tissues a distance of 0.66 
cm. the injection will usually enter the sphenopalatine ganglion. 
After the injection the patient generally experiences pain more or 



358 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

less severe, but which he recognizes as different from the neuralgic 
pain, and lasting from two hours to three days. 

The Antrum of Highmore (Maxillary Sinus or Sinus 
Maxillaris). — These structures, two in number, one in each supe- 
rior maxillary bone (Fig. 2), are the largest of the connected nasal 
structures. Anatomically, a brief study of each cavity, to the article 
on which the reader is referred, shows many peculiarities favor- 
able to the origin of morbid processes. Fig. 141 shows a normal 
antrum and its anatomical relations. First of all may be noted 
the comparatively large size of the antrum, with its one opening so 
situated as to make the chamber practically a dependent cavity 



CL€,C 




BH^hI 


iHSRI^ a7rL s 




'■'''*■, 


SfcSHLt--*^ 




• 


,# ^ 


f i.s r . 


}: , r r-fA 


up 'Sk m 3 


'7& 










M/o 




HP 1 * 



Fig. 141.— Anterior wall of antrum removed (after Cryer) : a.e.c, anterior ethmoidal 
cells; h.s., hiatus semilunaris; u.p., uncinate process; m.s., maxillary sinus ; i.t., inferior 
turbinate; Ira., inferior meatus; o.m.s., opening into maxillary sinus; In., infra-orbital 
nerve; ra., muscles of face; h.p., hard palate; a.p., alveolar process; i.s., infra-orbital 
sinus. 



suited for fluid-retention. The small size of the opening, with its ready 
occlusion by even slight turgescence of the investing membrane or 
encroaching growths, its situation so as to be bathed by the constant 
dripping from the ethmoidal- or frontal-sinus discharge, as well as to 
admit it to the antral cavity indirectly, or by direct communication, as 
shown in Fig. 145, and the continuity of nasal and antral membranes 
which it permits, are all features of importance. The floor of the 
antrum shows either conical projections marking the fangs of a 
varying number of the upper teeth, or is directly penetrated by them 
(Fig. 6) ; while the posterior dental vessels and nerves traverse the 
spaces to their respective distributions. This close relationship of 
teeth and antrum, especially if the extraction of a tooth has given 
fairly free buccal communication to the antral cavity, is a very 



CATARRHAL INFLAMMATIONS. 



359 



important factor in the etiology of many morbid conditions. Too 
much importance cannot be attached to "the teeth as a causal factor 
in antral lesions. A majority of cases, I believe, are due to disease 
of the teeth, and the rhinologist should possess a thorough knowl- 
edge of these structures and their relation to the antrum, or else call 
in consultation the dentist. As has been pointed out by Cryer, occa- 
sional branches of the superior dental nerve cross along the floor 
of the antrum, being protected only by the thin layer of mucous 
membrane lining that cavity. In such cases the slightest inflam- 
matory process or accumulation of fluid will be followed by pain 
out of proportion to the other symptoms. 

The opening of the antrum varies in individuals as to location, 
also in number, as shown in Fig. 142. In a number of cases the 




Fig. 142.— Outer wall of the antrum removed, showing two openings into the cavity: 
o, openings into the antrum (after Cryer). 

opening is much higher than normal, in reality being above the 
level of the floor of the orbit. In such cases there is marked 
tendency to accumulation of fluid should any inflammatory process 
take place. 

In diseases of the antrum the discharge will vary according to 
the position of the patient. This is true whether one or both sides 
be affected. 

CATARRHAL INFLAMMATIONS. 

Acute Catarrhal Inflammation. — This may arise with the 
existence of an acute rhinitis of whatever type, and is thus an 
extension of inflammatory process from the nose to the antrum, 
and the etiological factors of the first become of potential import 
in the secondary involvement. Temporary closure of the ostium 
maxillare, or antral opening, is a probable cause in some instances, 
and spread of inflammatory phenomena, by contiguity of tissue 



360 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

from inflammatory conditions in the alveolar or adjacent struct- 
ures, is not unlikely to take place. Some cases may be traced 
to the entrance of the discharge from the frontal or ethmoidal 
sinuses through the antral opening, or to abnormal communi- 
cation, as shown in Fig. 145, or to the entrance of foreign mate- 
rial, as in powder insufflations or in the use of the nasal douche. 
It may follow the reception of traumatism, accompany the nasal 
symptoms of the acute infectious diseases, or be a part of a general 
manifestation of some more distant lesion, as of the heart or kid- 
neys. Some cases are traceable to the presence of animate and 
inanimate foreign bodies, in which latter category may be included 
as foreign elements certain tumors, teeth, and the like. It may be 
associated with systemic poisoning from drugs or metals, such as 
arsenic, lead, and mercury. The tendency is for a spontaneous 
recovery upon the removal of the existing cause, though it may 
be the initial stage of a chronic condition, an exacerbation of the 
latter, or quite possibly go on to suppuration. Both sinuses or 
only one may be implicated. The symptoms peculiar to the con- 
dition are not marked, and consist of deep-seated pain in the upper 
jaw of the affected side, with pain in the teeth supplied by the 
nerves traversing the inflamed antral space. Tenderness on 
pressing the upper teeth may possibly be elicited, and some intra- 
orbital pain be felt. Inspection is of practically no diagnostic 
value, the slight secretion from the antrum mingling undiffer- 
entiated with that of the affected nasal mucosa. There is usually 
some edema of the nasal mucosa on the antral side. The diagnosis 
can be easily made in a typical case. The prognosis, as a rule, is 
good. 

Treatment. — A word as to treatment, in general, of all the 
accessory sinuses. Whether the condition is acute or chronic, 
whether the suppurative process is open or confined, I must urge 
conservatism in the treatment of these cavities. My own expe- 
rience confirms this statement that in many cases, if diligent and 
careful treatment is directed toward the normal orifices of the 
involved cavity with the idea and aim of re-establishing drainage 
through the normal opening, many of these so-called operative 
cases can be entirely cured without any operative procedure. This 
being the case, the patient is relieved of the disfigurement, of the 
prolonged and continued suffering following such radical opera- 
tion, and does not have the trying experience of having gone 
through obliteration of his accessory cavities. I do not mean 
by this statement that never are we to perform the radical opera- 
tion, but I wish to call attention to the fact that many cases which 
are subjected to the radical operation could be cured without 
any such procedure. As the inflammatory process involving 
the mucous-membrane lining of the antrum does not differ from 
mucous-membrane inflammation elsewhere, the treatment would 



CATARRHAL INFLAMMATIONS. 361 

apparently be the same ; but, unfortunately, it is practically a 
closed cavity, and the small opening into the nose may be occluded 
by the inflammatory process, either within the antrum or within 
the nose. If there be no infection and merely an acute inflam- 
mation, efforts should be made to establish drainage through the 
antral orifice. As there is usually associated an inflammatory 
condition of the nasal mucous membrane, this should be 
treated as in acute rhinitis. However, I believe there should 
be applied about the hiatus an 8 to 10 per cent, solution of cocain, 
in order to contract the tissues and establish drainage. In the 
early stage of the inflammation, good results may be obtained by 
the application of cold, in the form of ice-bags or cold-water pack, 
over the nose and antrum. If the inflammation progresses rapidly 
and there is marked nasal swelling, good results will be obtained 
by the application within the nostril of 40 per cent, ichthyol 
in lanolin. By this treatment I have been able to abort a 
number of cases. There should be administered a cathartic fol- 
lowed by a saline, and, if the catarrhal inflammation is associated 
with or the result of a cold, the administration of a 5- to 10-grain 
Dover's or 5-grain Tulley\s powder will aid very much in con- 
trolling the attack. Should the secretions become retained in the 
antral cavity, with occlusion of the orifice, it will necessitate the 
surgical opening of the antrum. The best point of drainage is 
from the lowest part of the cavity ; therefore, if it becomes 
necessary to drain, the opening should be made at the most 
dependent portion which will permit of a through-and-through 
drainage and allow of thorough cleansing. This is through the 
alveolar process of the superior maxillary or the canine fossa, yet 
the variation in the size and shape of the antra must always be 
considered. Some advocate the opening through the nostril, which 
is an attempt to establish drainage from the top ; besides, there is 
danger of leaving a permanent opening in the antrum, which may 
result in a chronic inflammatory condition. 

Chronic Catarrhal Inflammation. — This condition may 
occur as the result of repeated attacks of the acute form, or as a 
prolongation of an acute attack through persistence of its exciting 
cause. It is, however, usual for suppuration of the acute or 
chronic type to ensue upon the foregoing conditions, rather than 
the establishment of a non-infected chronic inflammation. The 
course varies, and suppuration may be only a delayed feature of 
the process. Continuation may lead to the closing of the antral 
orifice, steady accumulation of the mucoserous discharge, and the 
establishment of what may be properly termed hydrops antri. Or, 
as in the chronic forms of nasal inflammation, the membrane may 
become the site of low-grade cell-proliferation, the formation of 
myxomatous masses occur, and the antrum may become filled with 
a soft, semi-solid, translucent material, constituting a condition 



362 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

known as mucocele, which we will consider elsewhere (page 382). 
Pathologically, the inflammatory phenomena, as shown by a few 
post-mortem examinations, are identical with those exhibited in 
mucous membranes elsewhere, the membrane being thickened, 
pale, and showing a granular appearance. 

Symptoms. — The symptoms vary, largely in accordance with 
the freeness of the vent which the secretion of the antral membrane 
has. In general, they are similar to those observed in the chronic 
suppurative condition, without the systemic and local manifesta- 
tions of confined pus, or the intermittent purulent discharge into the 
patient's nostril, with its subjective annoyances. There is usually 
a sense of uneasiness in the affected sinus, or it may be a dull 
ache. At more or less frequent intervals there is a discharge into 
the nostril of the affected side of a clear, glairy, somewhat tena- 
cious, mucoserous material, the evacuation of which noticeably 
relieves the uneasiness felt in the region of the upper jaw. Inspec- 
tion may possibly reveal the discharge beneath the middle turbinal 
of the affected side, especially if the excess be wiped away and the 
head put in such a position as to allow gravity to favor its exit for 
a second observation. Should, however, the escape of the secre- 
tion from the antrum be prevented and its gradual accumulation 
take place, a train of severe symptoms follows. Distention of the 
antrum occurs, and the thin walls allow the swelling to become 




Fig. 143.— Cross-section through the orbit (after Cryer). The antra dip in under the 
floor of the nose. The sinus could be drained from the palatal aspect of the mouth. The 
septum is practically normal. 

noticeable in all directions. The eyes may be congested and pro- 
truded, the cheek swollen, the teeth sore and, subjectively, seem 



CATARRHAL INFLAMMATIONS. 363 

too long in masticating, the hard palate may be bulged, and all 
the overlying structures show congestive appearances. When the 
antra extend under the floor of the nose, as shown in Fig. 143, the 
swelling Avill involve the upper lip, and there will be marked 
tenderness of the incisor teeth. Dulness and fluctuation may be 
elicited. Pain of a tense character becomes marked, and the 
greatest discomfort ensues until relief is had from nature or the 
physician's art. 

The diagnosis of chronic catarrhal inflammation of the antrum 
may be sometimes clearly made, but is often obscured by the 
attendant nasal process, unless obstructive phenomena develop. 

The prognosis for life is excellent, though the cure or relief 
of the condition itself is dependent upon many factors. 

Treatment. — Simple chronic non-infected inflammation of the 
antrum is not common, the infected form being more frequently ob- 
served. However, should the simple chronic inflammation exist, 
while treatment through the nasal opening may in some cases be effi- 
cacious, yet by far the best results will be obtained by opening from 
below through the canine fossa (see page 376), with a thorough 
curetment of the antrum and the establishment of free drainage. 
For curetment the instrument shown in Fig. 144 is the best. This 
surgical procedure should be resorted to only when there is accu- 
mulation within the antrum, giving rise to pressure-symptoms. If, 
however, the secretions are not retained within the antrum, and 
there is still drainage through the nose, some benefit may be 
obtained by treatment through the nasal channel. However, in 
the chronic form this usually only temporizes, and the condition 
goes on from bad to worse, or becomes infected and causes 
empyema of the antrum. Should the nasal opening in the antrum 
be closed, and drainage be established through the alveolar process 
of the maxillarv bone or the canine fossa, better results will be 






O— O— O— o— 



Fig. 144.— Myles' antrum-curets, with flexible shank. 



obtained if the nasal opening is allowed to remain shut and drain- 
age is kept up from below until the inflammatory process is allayed. 
By allowing the opening into the antrum through the nose to 
remain closed, much can be done to avert infection, as the open- 
ing through the canine fossa can be performed under antiseptic 
precautions, thereby eliminating the danger of infection. 



364 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

OZENA OF THE ANTRUM. 

But little can be said of this condition, other than that it some- 
times accompanies nasal ozena, or at least has been found by post- 
mortem examination or operative procedure on the antrum to exist 
independently of the nasal condition. Its etiology and pathology 
are probably the same as of the similar process in the nose. It pre- 
sents no peculiar symptoms save those usually observed in nasal 
ozena, and inspection is of no avail in determining the existence 
of ill-smelling crusts. It may be that in its occurrence there is an 
explanation of the occasional exhibition of nasal ozena unaccom- 
panied by crust-formation. 

Diagnosis must, so far as known, rest upon the suspicions which 
the latter condition may provoke. The prognosis is good as regards 
life, but should be very guarded as to relief of the condition. 

Treatment. — Ozena of the antrum is either associated with 
nasal ozena, necrotic processes involving the bony framework of 
the antrum, usually from involvement of the teeth, or the escape 
of fetid gases generated by decomposed tissue at the base of the 
diseased tooth finding its outlet by continuity or contiguity of 
tissue through the antrum. The treatment should then be directed 
toward the underlying cause. 

EMPYEMA OF THE ANTRUM. 

Acute Purulent Inflammation. — Empyema of the antrum 
is usually preceded by a catarrhal inflammation, the secretion of 
which is more or less confined to the antral cavity, and with the 
access of micro-organisms assumes a purulent character. In the 
patients in whom the condition is noted, there may be observed a 
general impairment of the economy, some cachectic condition or 
diathetic strain, particularly tuberculosis. The abuse of certain 
drugs, as, for example, mercury, is said by some to exert a strong 
predisposing influence. Division of the fifth nerve may also be a 
causal factor. The catarrhal processes attendant upon the infec- 
tious diseases, such as measles and scarlet fever, are , especially 
prone to become purulent.. It is rarely observed in children 
because of the incomplete development of the antra before puberty, 
though cases have been reported by competent observers in which 
infection was believed to have taken place during parturition. 
Traumatic conditions are more likely to be followed by suppura- 
tion than by simple catarrhal manifestations. The source of infec- 
tion may be traced in several ways. It may enter through the 
ostium maxillare with a small portion of an infected rhinitis dis- 
charge, follow a similar entrance of purulent discharge from 
the frontal or ethmoidal sinuses, or be conveyed by some penetra- 
ting traumatism. A large proportion of cases originate from an 



EMPYEMA OF THE ANTRUM. 365 

existent suppurative disorder at the roots or adjacent tissue of the 
teeth related to the antrum, or from a tooth-socket which permits 
entrance of infection from the mouth. Too much importance 
cannot be attached to the important relation which the teeth con- 
nected with the antrum bear to its pathology. Seventy per cent. 
of the cases are due to this cause. The pathological phenomena 
do not differ from those that attend purulent processes of mucous 
membranes elsewhere. The symptoms of the condition are, as a 
rule, fairly prominent. There is an abundant unilateral discharge 
of pus from the nostril, which may be constant, or, as more often 
happens, comes suddenly and with marked remissions. If, how- 
ever, both antra, as occasionally happens, be involved in the proc- 
ess, the discharge is bilateral. The purulent outflow is usually 
yellowish, and may have an odor slightly or markedly fetid. Rarely 
is it blood-streaked. The patient may notice that he is able often 
to bring on the discharge by bending his head obliquely down- 
ward and forward, so as to permit gravitation of the material. 
Pain is a variable symptom, but in these acute cases with free 
outlet of the purulent material it is not apt to be severe. Usually 
it is of a dull, heavy character, and vaguely localized in the head 
and cheek, becoming more annoying as the antral cavity fills with 
pus, and being relieved by its evacuation. Tenderness may be 
found over the antrum by percussing the cheek or tapping the 
teeth ; while, should there be a small fistulous opening through the 
socket of an extracted tooth, a small quantity of pus may be 
observed at its orifice. There may possibly be evidences of a 
mild systemic infection, chill, headache, sweats, and the like, and 
if the discharge be drawn back into the posterior nares and swal- 
lowed, temporary gastric disturbance may result. Anterior rhino- 
scopy may show the presence of pus coming from beneath the 
middle turbinal of the affected side, though the mere presence of 
pus in this site is not absolutely diagnostic. If, however, the 
turbinal be cleansed of pus, the head bent obliquely forward and 
downward, with the ear of the affected side upward, and the dis- 
charge of pus be again observed in this site, it may be regarded 
as of antral derivation. The coexistence of suppuration of the 
remaining accessory sinuses must be" borne in mind. The diag- 
nosis of the condition may be simple or attended with consider- 
able difficulty. The intermittent discharge of pus, its location by 
rhinoscopy, and the heavy, uneasy sensation in the antrum should 
be suspiciously regarded. Confirmatory data may be sought in 
various ways. 

If hydrogen peroxid be used for its diagnostic value it must 
be well diluted, for the rapid decomposition of pus by this agent 
in a practically closed cavity is attended with extreme danger of 
a rupture. The introduction of a small electric lamp into the 
mouth, for the purpose of transillumination, has been advised 



366 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

and is practised, the theory being that pus in the antrum will 
show as a darkened area before the light. But while this, 
ingenious method has undoubted value, it is not to be wholly 
relied upon, for while a collection of pus in the antrum offers 
obstruction to the passage of light, yet the author wishes to 
lay great stress on the fact that obstruction to light in this loca- 
tion is not by any means restricted solely to the presence of pus. 
The irregularity in the size of the antrum and the irregular thickness 
of the bony walls renders this procedure very unreliable. External 
swelling and discoloration may exist, and may be slight or marked. 

The prognosis of the condition is variable. Many cases go 
on to a speedy termination and, after a continuous or remittent 
flow of a few days, subside altogether. It may be the starting 
point of a stubbornly-intractable chronic suppuration, or if its 
antral exit be occluded, it may precede a severe confined sup- 
puration. The outlook for life is favorable. 

In the Young. — Empyema of the antrum in the very young 
is an exceedingly rare condition. Only a few cases have been 
reported. The local symptoms, on account of age, are all that 
will direct the attending physician's attention to the diseased 
area, and the involvement can be scarcely blamed upon nasal 
or dental conditions, as the sinus in the very young is a mere 
rudimentary cavity and does not develop until from the fourth 
to the eighth year ; so that involvement of these sinuses in 
the very young would show some abnormality in the anatomical 
structures. 

Chronic Purulent Inflammation. — The causative influences 
in operation here are largely the same as in the acute suppurative 
form, and in many cases the chronic type is a direct continuance 
of the acute. Prolonged irritation, as from a carious tooth or per- 
manent abscess-sac at a dental root, are not unusual etiological 
factors. Any of the processes, simple or infectious, may and fre- 
quently does follow grippe. The presence of a foreign body may 
cause it, however introduced, whether by traumatism, by influx 
from a nasal douche, or comprised in pent-up secretion retained 
more or less permanently through partial occlusion of the antral 
outlet. It may follow traumatism, or perhaps even be a post- 
operative complication of nasal surgery. One case observed in my 
practice was due to the use of arsenic by the dentist for the pur- 
pose of destroying the nerve in a decayed tooth. The application 
was made twice in three days and not seen for several days after- 
ward, when the antrum was involved and extensive tissue-necrosis 
had occurred with infection. In another case, extensive necrosis 
and suppuration had followed the injection of chlorid of zinc into 
a tooth-cavity which connected with the antrum. Constant drip 



EMPYEMA OF TEE ANTRUM. 367 

of a suppurative discharge from the ethmoidal or frontal sinuses, 
or from direct communication, as shown in Fig. 145, may keep 




Fig. 145.— Section of the skull of a negro (after Cryer). The thickness of the antral 
floor is to be noted ; also the probe passing directly from the exit of the frontal sinus into 
the antrum; thickened turbinates; wide nasal cavity: m.t., middle turbinate; i.L, 
inferior turbinate. 

irritation and suppuration active. It may be the result of confined 
suppuration, whether that be an acute or chronic manifestation. 
Some authors make, in classifying, two forms of the chronic type, 
the form in which free exit and evacuation of the purulent mate- 
rial are permitted, the so-called active form ; and a second, in 
which, the outlet being barred, accumulation of pus takes place 
in the antrum, and the characteristics of an abscess appear, the 
so-called latent form. The latter, however, may occur in both 
acute and chronic cases of antral suppuration, and is a confined 
suppuration — in fact, a true empyema, under which title it will 
receive separate consideration. Pathologically, the same processes 
are to be observed that occur in chronic pyogenic conditions of 
mucous membranes elsewhere, and have already been described. 
The symptoms, like the causes, are for the most part modifications 
or intensifications of those accompanying the acute disorder. There 
is a discharge from the affected nostril, either more or less con- 
tinually or in intermittent periods, once or twice a day, or oftener. 
It varies in amount and may be abundant. The color of the dis- 
charge is usually a bright yellow, and has more or less of a fetid 
odor, though not so marked as in syphilitic ulceration or ozena. 
The prone position favors its discharge, and during sleep it may 



368 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

run down the posterior nares and collect in the pharynx. Cough 
is by no means infrequent — the short, hacking cough, repeated 
painfully often, that attends an irritative drip from the choanse. 
The patient's general spirits are apt to be depressed, and he be- 
comes gloomy because of the repugnance to him that he fancies 
his acquaintances have, and which he imagines arises from the 
subjective annoyance of the fetor of the discharge. This is, in 
reality, not offensive to surrounding persons, but an evidence 
of his own unimpaired sense of smell. A bitter, acrid taste or 
mawkish sweetness may be experienced, while not infrequently 
the swallowed discharge is responsible for more or less gastric 
disturbance. The general health is often impaired. Pain locally 
is not severe, and varies from almost nothing to an intense dull 
aching, often referred to the teeth. There may be more or 
less pain of an intermittent character referred to the frontal or 
supra-orbital regions. Tenderness on tapping the teeth or the 
cheek may be often elicited. Rarely may inflammatory con- 
gestions and the like be noted in the fundus or conjunctiva of the 
eye of the affected side. Systemic symptoms may be present. 

The diagnosis rests upon the symptoms enumerated, taking 
care to exclude manifestations from the other sinuses in the exami- 
nation. Transillumination, puncture, and hydrogen-peroxid intro- 
duction are to be regarded with the same restriction noted in the 
acute process. Careful examination of the gums and teeth of the 
upper jaw of the affected side are to be made, and note carefully 
taken of any suspicious dental abscess, gum-boils, or pus-dis- 
charging fistulae that may be present. 

The prognosis for life is good. The condition may be over- 
come gradually by drainage, antiseptics, and the like, but at the 
best it is an intractable and difficult process to handle. Spon- 
taneous recovery is very rare. 

Confined Suppuration. — By this term is meant the progres- 
sive formation and accumulation of pus within the cavity of the 
antrum and without vent ; " pent-up pus," in other words. The 
condition usually arises in one of three ways. It may be the 
result of an acute suppurative process occurring in an antrum 
with orifice already occluded, or shortly followed by occlusion in 
inflammatory or other morbid phenomena. Again, in practically 
the same manner it may be originated during the existence of a 
chronic suppurative inflammation, or even be its initial stage. In 
the third place, the confined accumulation of mucoserous discharge 
in the antrum, to the designation of which, as " hydrops antri," 
we have already called attention, may become infected, and sup- 
puration result. Primarily, then, the etiological elements of the 
empyema are embraced in those causative of the conditions in 
which it originates. Emphasis must be laid, however, upon the 
greater role that infection from the related dental structures must 



EMPYEMA OF THE ANTRUM. 369 

bear in this connection, than in the production of the pre-exist- 
ing process. The causes of occlusion present a wide range of 
variation. Rarely it may be congenital. It may follow a tur- 
gescence of the nasal mucosa in an acute coryza during the exist- 
ence of an acute infectious disease, especially with marked nasal 
symptoms, or in any condition attended by swelling of the nasal 
membrane. The enlargements of hyperplastic rhinitis may pro- 
duce it, as may the proximity of growths, such as polypi and the 
like, especially if they be within the antrum and act as a valve 
against the orifice on its inner aspect. In the same way conges- 
tive turgescence caused by the proximity of a neighboring tumor 
may give rise to occlusion of the orifice, and a similar condition 
may follow swelling of the antral mucosa. Plugging of the orifice 
may also take place, though rarely by a small foreign body, such 
as a roll of diphtheritic membrane. Usually the development of 
the trouble is somewhat insidious. The region of the antrum 
becomes tender to pressure, especially on the teeth ; a sense of ful- 
ness and heaviness develops, with possibly a dull headache. Pain 
is present and becomes progressively worse, in addition to which 
there may be throbbing and beating, accompanied by a dull 
headache referred to the supra-orbital region, the infra-orbital 
region, or the bridge of the nose. The teeth supplied by the pos- 
terior nerves passing through the antrum ache, and more than one 
dentist, in removing a tooth for its aching and inflamed condition, 
has seen a stream of pus as thick as a pencil lead flow from the 
socket, with a relief to the patient that is indescribable. Swell- 
ing continues, and may in extreme cases reach a degree almost 
beyond belief. The nostril of the affected side may be completely 
occluded, the hard palate bulged out, and even spontaneous rupt- 
ure through this structure may occur ; the cheek may be swollen 
and rounded, the eyeball protruding from its socket, the conjunc- 
tiva congested and reddened, vision impaired, and the lids over- 
flowing with the lacrimal secretion that an occluded duct does not 
remove. The overlying surfaces are hot to the touch, reddened, 
congested, and edematous ; pain is constant and severe, tenderness 
is excessive, and the teeth seem starting from their sockets, caus- 
ing a subjective sensation of being too long. Mastication is pain- 
ful, speech is impaired, and sleep is impossible. The general 
symptoms of pus-intoxication may appear as sweats, chills and 
rigors, elevated temperature, and high-colored urine. The antral 
walls may be so thinned and tense as to crepitate on pressure. 
Dulness may be marked on percussion, and fluctuation may be 
elicited. Finally, with the intensification of the symptoms, there 
is found at some point a weakened resistance that favors a thin- 
ning and rarefaction of the overlying tissues, and permits the evac- 
uation of the pus with, it may be, the establishment of a more or 
less permanent fistula. The opening may take place through the 

24 



370 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

palate, alveolar process of the superior maxillary, into the orbital 
cavity, cheek, or into the nostril. With the establishment of the 
opening and the evacuation of the pus there is a rapid fall of the 
severe symptoms, followed, perhaps, by the establishment of a 
chronic suppurative inflammation. 

The diagnosis, when the condition is well established, is easy ; 
but before the swelling occurs may cause some confusion. It 
must be made on the examination and symptoms, and transillumi- 
nation is possibly of corroborative importance. 

The prognosis for life is good. The duration of the suppura- 
tive process may be of rapid course, as in any acute abscess, or 
practically lie dormant, sluggishly developing for many years. 
After the evacuation of the pus, either through nature's efforts or 
the surgeon's art, a guarded prognosis must be given as to the 
duration of the resultant chronic suppurative inflammation and 
discharge. The development of grave intracranial lesions, as well as 
fistulous formation, is to be carefully considered in this connection. 

Lutz has found the use of alcohol in strengths of from 50 to 
95 per cent, valuable in the treatment of suppurating sinus. After 
perforating the naso-antral wall and washing out the sinus with 
hot boracic acid or normal salt solution, he injects into the antrum 
50 per cent, alcohol, and with the patient's head turned downward 
toward the affected side allows it to remain ten or fifteen minutes. 
The patient is then asked to blow the nose " wide open" in order 
to clear the sinus. In successive treatments the strength of the 
alcohol is increased until after three or four it reaches its maximum. 

Transillumination. — Although from a standpoint of diag- 
nosis of lesions of the antrum transillumination is a valuable aid, 
it is by no means an infallible agent. As a rule, by placing either 
in the mouth or in the nasopharynx a strong electric light, having 
the patient in a darkened room, if the antral cavities be of equal 
size and the bony walls of equal thickness, they will show as 
clear areas on either side of the nose. However, there is great 
variation in the size of the antral cavities and in the bony walls, 
as illustrated in Figs. 145, 146, which would necessarily control 
the transmission of light. Should the antral cavity be filled with 
pus or any foreign material, attempts to illuminate it will show 
a dark outline similar to the solid, bony, adjacent structure. 
That the darkened outline does not positively indicate that 
the antrum is filled with pus is proven by the fact that there 
may be thickened antral walls, with small or even absent cavity ; 
or the entire space may be filled by a new growth, either benign, 
malignant, or cystic, which will produce the same result. These 
objections, however, do not detract from the necessity and impor- 
tance of transillumination in every case. In attempting to detect 
the difference of opacity, in comparing the two cavities, care must 
be taken in darkening the room, as any side light may lead to an 



EMPYEMA OF THE ANTRUM. 



371 



error in diagnosis by causing one antrum to transmit the light 
apparently much better than the other. Considerable importance 
should be attached to the illumination given to the floor of the 
orbit, which shows as a line underneath the lower eyelid. In my 
own experience, in a number of cases in which much difficulty in 
illumination of either antrum was experienced, the diagnosis was 
based on the interference with the orbital illumination, which was 
much darker on the diseased side. Much better results can be 
obtained, I believe, by the introduction of the incandescent lamp 
(Fig. 29) into the nasopharynx. This not only gives thorough 




j^ I( L" 146 -~ Cross-section illustrating asymmetry of nasal fossa?, caused by redundant 
and deflected septum. The disparity between the 'size of the two antra is to be noted. Is 
it not likely that the pressure of the deflected septum transmitted through the turbinate 
would lessen the size or prevent the development of the adjacent antrum, with perhaps a 
compensatory enlargement of the other antrum ? There is a false union (synechia) at the 
point marked X, between the septum and turbinate : e.a., enlarged antrum': d.a., dwarfed 
antrum; m.L, middle turbinate ; s.d., septal redundancy ; i.t., inferior turbinate (Cryer). 

illumination of the antrum, but also the velum may be strongly 
illuminated, and by the aid of the nasal speculum the nares may 
be carefully and thoroughly inspected. 

For illumination through the mouth many special lamps have 
been devised, varying only in points of construction, there being 
very little difference in the illuminating powers. Fig. 147 shows 
a lamp as useful as any. In illuminating through the mouth, 
should the patient have false teeth, the plate should be removed ; 
otherwise, it will obstruct the transmission of light and lead to 
faulty conclusions. 



372 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

The importance of transillumination and its aid in diagnosis is 
controlled largely by the associated clinical symptoms. In illumi- 
nating the antrum the age and sex of the individual must also be 
considered, as in women and children the cavity is likely to be 
situated higher than the level of the floor of the nose, and the 
walls are apt to be thicker. In advanced life the walls are much 
thinner, as shown in Fig. 148. 

While transillumination is of undoubted value, yet too posi- 
tive reliance cannot be placed on it, as altered anatomical condi- 
tions will preclude the possibility of accuracy, which may lead 
to uncertain and incorrect diagnoses, with uncalled-for operative 
procedures. 




Fig. 147.— Coakley transilluminator for the antrum and frontal sinus. 

A simple and satisfactory method of transillumination is by the 
use of the tube attached to the Koch lamp, which was devised by 
Koch for microscopical work. The long-curved, solid, glass tube 
which transmits the light at the end can be inserted in the mouth 
or nasopharynx, giving a fair transillumination. There is abso- 
lutely no heat, thereby lessening the discomfort to the patient. ^ 

Transillumination of the frontal, ethmoidal, and sphenoidal 
sinuses, owing to their location, is of very little positive aid. 

If all the accessory cavities, or even a majority, adhere closely 
to the forms denoted as typical, transillumination would be a 
most valuable aid in diagnosis of the diseases. 

The atypical cases, however, in point of numbers, outweigh 
the typical, and hence it is that this method can never be of great 
service. Transillumination may uphold a diagnosis, but without 
absolute clinical proof of the presence of certain morbid condi- 
tions, conclusions based upon its results should not be considered 
infallible. # 

Complications.— Caries may occur in any of the bony wails 
of the antrum, resulting in rupture with abscess formation in the 
neighboring structures. On the other hand, abscess formation in 
the region outside of the antrum may take place without caries of 



EMPYEMA OF THE ANTRUM. 



373 



the bony walls, the infection traveling along the foramina for the 
nerves and vessels. Orbital abscess is the most serious complica- 
tion, as it may lead to intracranial involvement, either through the 
optic foramen or the roof of the orbit. Intracranial complications 
without infection of the orbit rarely occur, as there is no direct 
anatomical relation between the antrum and the cranial cavity. 




Fig. 148.— \ ertical section showing the thinning of the antral floor ; the large size of 
both antra ; the septa crossing the antra, springing from the floor, and subdividing the 
lower portion (after Cryer) : o., orbit; s., septum; m.L, middle turbinate; m.m., middle 
meatus; r.m.s., right maxillary sinus ; i.t., inferior turbinate ; l.m.s., left maxillary sinus ; 
e.r., septal redundancy. 

Treatment. — For the treatment of empyema of the antrum, 
either of the acute or chronic form, many plans of procedure have 
been given. This multiplicity only establishes the fact that no 
fixed plan can be adapted to every case, yet I do believe that the 
method which establishes drainage from below is the one to be 
used, the extent of the surgical interference depending entirely on 
the severity and gravity of the case. 

The treatment, then, of pus in the maxillary sinus, whether it 
be due to acute or chronic inflammatory process, or whether it be 
a confined suppuration, necessarily depends largely on the cause. 
If the infection of the antrum and the cause of suppuration be of 
nasal origin, the treatment should be through the nasal cavity. If, 
however, it is associated with dental caries, then the treatment 
should be directed from below through the alveolar process of the 
superior maxillary. The antral cavity is so situated as to subject 
it to exposure by extension of disease from adjacent structures, with 



374 DISEASES OF THE ANTERIOR NASAL CAVITIES. 



the nasal tract forming one of its lateral walls as a constant source 
of infection ; while the floor is in close relation to the first and 
second molar teeth, and is liable to infection by extension of patho- 
logical processes in either case. Besides, the tendency to exten- 
sion from the teeth may be increased by irregularities in their 
location. While it is impossible to lay down any rule which 



f 



BaaaaagEBS 




Fig. 149.— Myles' curved trocar. 



would be applicable to all cases, yet the antrum should be treated 
either by way of the intranasal structures or by the more radical 
surgical procedure of opening through the bony wall below. The 
intranasal method consists in restoring, as far as possible, the nasal 
chambers to their normal condition. This can be done by the 




Fig. 150.— Douglas' antrum perforator 



Fig. 151.— Thepsco aspirating apparati 



application of disinfecting sprays and the irrigation of the sinus 
through the natural orifice or an artificial opening through the 
lateral wall. If this artificial opening is to be established, the 
best method is that given by Mikulicz, or some modification 
of it. This consists in opening the sinus through the inferior 
meatus with a spear-shaped knife, the blade being placed at an 



EMPYEMA OF THE ANTRUM. 375 

obtuse angle, and having a flange to regulate the depth of the 
incision. This is introduced into the nasal cavity with the point 
toward the floor, and, when just under the natural opening of the 
sinus, the instrument is turned outward and with a sharp thrust 
made to penetrate the inferior meatus into the antrum. A some- 




Fig. 152.— Jackson's cutting forceps. 

what triangular opening is made, which, being near the floor, will 
permit of thorough cleansing and free drainage. This opening 
can be made either with the knife, curved trocar and cannula, the 
antrum drill (Fig. 149), or the Douglas antrum perforator (Fig. 
150). The intranasal operation cannot be well performed if the 
nasal chamber is unusually narrow, either from natural formation, 




Fig. 153.— Ostrom's biting forceps. 



enlarged turbinates, or deflected septum. The Brawley or Thepsco 
aspirating apparatus, shown in Fig. 151, is a valuable one for free- 
ing the nasal accessory sinuses of secretions and for the removal of 
pus in suppurative cases. If it is desirable to establish free drain- 
age through the nose and break down the wall into the antrum, 



376 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

the Chevalier Jackson or Ostrom biting-forceps, as shown in 
Figs. 152 and 153, is the best instrument for this purpose. From 
below, the easiest method of penetration is through the canine 
fossa. If, however, the set of teeth is complete, the opening may 
be made either between the first and second molars, or between the 
first molar and the second bicuspid. Should any of the teeth 
from the first bicuspid to the first molar be out, the opening should 
be made through the socket (Jameson). The great variation in the 
size, shape, and location of the antrum, as well as the variation in 




Fig. 154.— Method showing the enlarging of the ostium maxillare (Ostrom). 



the thickness of its walls (Fig. 156), must always be taken into 
consideration. 

It is desirable to preserve a tooth if possible, even though it 
be diseased ; and, before reckless extraction for the purpose of 
opening the antrum, the rhinologist should either have a thorough 
knowledge of the dentistry of this part, or should call in consulta- 
tion a thoroughly competent dentist. When once the opening is 
made from below, either through the canine fossae or through the 
tooth socket, the cavity should be thoroughly irrigated by means of 
a strong syringe with a curved tip (Fig. 233), and the antra should 
be filled to their utmost capacity with a warm saturated solution 
of boric acid. This should be followed by a solution of hydrogen 
peroxid of one-half strength. As to the question of a drainage-tube 
in the antrum from below, my own experience has been that not one 



EMPYEMA OF THE ANTRUM. 377 

that I have used is entirely satisfactory. I believe that the best re- 
sults will be obtained by thorough and frequent irrigation and by 
packing the opening with antiseptic gauze or cotton, which should be 
removed at first twice in twenty-four hours, and after two or three 
days once in twenty-four hours. The perforated drainage-tubes 
tend to clog, and are a constant source of irritation. By the plug- 
ging method, the cavity can be rendered aseptic and kept in that 
condition. If there is a tendency to the continuation of the infec- 
tion, owing to the localized areas of granulation-tissue within the 
antrum, by far the best result will be obtained by enlargement of 




Fig. 155.— Showing method of removing inferior meatal wall. 

the opening and thorough curetment of the affected area. This is 
a method much safer by far than the injection of astringents into 
the antrum. The insufflation of powders is highly recommended, 
but my own objection to the powders is that there is a tendency 
to cake or harden, and thus act as a foreign body and keep up irri- 
tation. The iodoform powder or aristol and boric acid seems 
the least likely thus to harden. In a case of prolonged suppura- 
tion necessitating curetment, the opening from below should be 
large enough to permit packing the antrum with antiseptic gauze. 
The gauze should be thoroughly impregnated with boric acid or 
acetanilid. In these cases, too, thorough exploration of the antrum 
may reveal the presence of a foreign body, such as a supernume- 
rary tooth, a portion of a diseased tooth which has been forced into 
the cavity, or a spicula of bone from necrosed areas. 



378 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

In attempting to open the antrum, the variation in shape and 
location of the cavity must always be taken into consideration, as 
marked irregularity exists in at least 30 per cent. Rarely are the 
two antra of the same size, as shown in Figs. 145 and 146. The 




Fig. 156.— Transverse vertical section of a negro's skull. Note the difference of shapes 
in the bullae ethmoidales and uncinate processes on the two sides ; the roughly triangu- 
lar shape of the antra; thickening of nasal antral floors: b.e., bulla ethmoidalis ; u.p., 
uncinate processes. 

variation in the size of the antral cavity necessarily controls the 
thickness of the wall and the difficulty of penetration. There may 
be complete absence of one antrum. 



NEGATIVE AIR PRESSURE IN ACCESSORY SINUS DISEASE. 

The application of negative air pressure in diseases of the 
accessory sinuses of the nose, not only for diagnostic purposes, but 
as a therapeutic measure as well, seems to be of value in certain 
cases, although all are not amenable to this treatment. When 
applied for the diagnosis of inflammation of the antrum very good 
results are obtained. It has been shown that an antrum filled 
with pus can be completely emptied by this method. In a similar 
manner the method can be employed for diagnostic purposes in 
frontal sinusitis and ethmoiditis, but it is difficult to distinguish 
between the two. 

The therapeutic effect of this method depends upon the hyper- 
emia produced in the mucous membrane lining the accessory cavi- 



EMPHYSEMA OF THE ANTRUM OF HIGHMORE. 379 

ties, as a result of which there is produced an increased nutrition 
to the part, the resistance of the cells is raised, leukocytosis is in- 
creased, and the infective process controlled. That suction actually 
produces hyperemia of the mucosa of the sinuses has been demon- 
strated. To what extent this treatment will shorten the duration 
of an acute inflammation it is difficult to determine. That the 
hyperemia in the mucous membrane of the accessory cavities is 
sufficiently intense to exert a curative effect is probably true. 
While it is doubtful that a cure can be produced in chronic cases, 
yet the removal of the secretion seems to be of assistance. Artificial 
drainage of the accessory sinuses by means of negative pressure 
following the Killian and other operations seems to be of distinct 
advantage in shortening the duration of the after-treatment. 

Various devices are employed for exhausting the air in the 
nasal cavities, the one shown in Fig. 151, devised by Brawley, I 
have found very satisfactory. This apparatus is attached to the 
faucet, and the negative pressure regulated by the amount of water 
turned on. The nasal tips are introduced and the soft palate 
brought into apposition with the pharyngeal wall by the act of 
swallowing, thus exhausting the air in the nasal cavities, and the 
pus is drawn out through the rubber tubing and into the reservoir. 



TUBERCULOSIS, SYPHILIS, GLANDERS, AND ACTINOMYCOSIS. 

These affections are all of possible location in the antrum, but 
are extremely rare, the latter two practically unknown, and, when 
so occurring, are concomitant with the nasal lesion of the same 
character. The symptoms, as a rule, are overlooked in connection 
with those of the greater involvement, and the diagnosis, if made, 
is due to consideration of the major lesion. 



THE ACUTE INFECTIOUS DISEASES. 

In some cases the antrum may be implicated in the nasal 
exhibition of diphtheria, erysipelas, small-pox, and the like. The 
importance of this invasion is, however, simply to augment the 
severity of the pre-existent lesion, and usually subsidence occurs 
coincidently, or terminates in simple chronic inflammation or infec- 
tious inflammation, and should be treated as given under these 
lesions. 

EMPHYSEMA OF THE ANTRUM OF HIGHMORE. 

Emphysema of the antrum of Highmore is a condition in which 
there is accumulation of gas in the antral cavity. Although it is 
not commonly met with, it is of great importance and is often 



380 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

overlooked. The prime factor in its etiology is the generation of 
gases from a decayed tooth which communicates with the antrum. 
The gases so originating may be confined to the cavity, either from 
some occlusive condition of the orifice by morbid processes, or 
through failure to find vent through the ostium maxillare. If the 
antral opening is not affected, the escape of the offensive gas into 
the nose will lead to the mistaken diagnosis of a nasal lesion with 
ozena, and the treatment will be directed to the unoffending nasal 
mucous membrane. 

This condition I have observed in five cases. In one case 
there was no intranasal lesion, and the main symptom that caused 
the patient to seek relief was the disagreeable and offensive odor. 
The other cases, however, had some irregularities within the nasal 
cavity, whose only significance is the possibility of their being so 
located as to occlude the antral opening. Age does not seem to 
be an important etiological factor, as the cases coming under my 
observation varied from childhood to past middle life. 

The symptoms vary, depending upon whether the antral 
opening is partially or entirely occluded. There is usually a sense 
of intranasal pressure, which may gradually increase. Pressure- 
pain is dull ; heavy, sickening headache is usually present, and is 
markedly increased by stooping forward. Disturbance of the eye, 
nose, and buccal functions may ensue. If the antral opening is 
closed, the accumulated gas will give rise to pressure-symptoms, 
the same as in confined suppuration of the antrum. Percussion 
over the antrum may give a variation in resonance, although this 
is of little value, owing to the great variation in the size of the 
antral cavity and thickness of its walls. Unless the condition is 
associated with an infected inflammatory lesion of the antrum, 
transillumination is of little value, as the confined gas will offer 
no obstruction to the rays. 

The diagnosis is not always easy, and may often be made 
only by exclusion. Lesions of the teeth may call attention to 
their genetic influence. The symptoms of dental irritation in this 
region, with subsequent cessation of pain and later development 
of pressure-symptoms in the cheek, with ozena that is continued 
or interrupted, should be always regarded as suspicious. There 
is usually an absence of the systemic phenomena of the presence 
of pus. 

The prognosis is excellent. The majority of cases recover 
spontaneously and rapidly after vent is given to the confined gas, 
and after proper treatment of the offending tooth or teeth or the 
removal of necrosed bone. 

The treatment, of course, consists in the evacuation of the 
confined gas, and this is usually better performed by the removal 
of the suspected tooth. Tapping of the antrum through the nose 



FOREIGN BODIES IN THE ANTRUM. 381 

may be performed, which will relieve the pressure-symptoms ; 
but, as the cause of the accumulation of gas is a diseased tooth, 
treatment should be directed toward the removal of the diseased 
structure, and necessitates the skilful aid of the dentist, or a 
thorough knowledge of the subject of dentistry by the rhinologist ; 
otherwise, teeth may be unnecessarily sacrificed. 

FOREIGN BODIES IN THE ANTRUM. 

These may be either inanimate or animate. The former clas's 
are formed of such bodies as ends of dental or surgical instru- 
ments broken during operations upon the upper jaw — e. g., 
cannulas, drainage-tubes — or cotton, etc. Rarely, foreign bodies may 
find entrance through a penetrating traumatism of the cheek, as in 
bullet wounds. In this light also are to be considered the occa- 
sional cases noted of an intra-antral tooth, a broken bit of bone, 
and the various tumors that may originate there. The symptoms 
may be wholly those of the persistent and stubborn catarrhal or 
suppurative processes engendered, and the presence of the foreign 
element may be only a matter of conjecture until an exploratory 
opening is made. The diagnosis may be made by the traumatic 
history, or be only tentative upon consideration of the catarrhal or 
suppurative symptoms. 

Treatment. — For the successful removal of foreign bodies 
from the maxillary sinus no fixed plan of procedure can be given, 
as different conditions will be presented with each case. Cannulas 
and the various forms of drainage-tubes which may be forced into 
the antrum can be removed by forceps or by the fine probe, one 
end of which is hooked, or long, narrow-bladed saw-scissors may 
be used. Copious injections of a tepid fluid may serve to float 
the body into such a position near the opening as to permit its 
being easily grasped. However, in many cases it will be neces- 
sary to open into the sinus through the canine fossa. 

The presence of animate bodies is yet more rare, but some few 
cases are on record in which insects and worms have made their 
way into the antrum through the ostium maxillare, and by their 
presence in the chamber caused serious mischief. The symptoms 
produced are those of a severe catarrhal or purulent inflammation, 
provoked by the presence of the dead body of the insect, or inten- 
sified into excruciating agony if it be still living and in active 
motion. The diagnosis may be confounded with severe neuralgia, 
suppurative inflammation, or pain referred to the teeth. The 
rarity of animal invasion may alone thwart a proper determina- 
tion until actual opening of the antrum and the removal of the 
irritating object be performed. The prognosis on removal of the 
foreign element, is good. 



382 DISEASES OF THE ANTERIOR NASAL CAVITIES. 



MUCOCELE OF THE ANTRUM. 

This may occur in the course or as a result of a chronic 
catarrhal inflammation of the antral membrane. Here, as in the 
formation of nasal myxomatous masses, the chronic inflammation 
may show a proliferation of low-grade cells, their accumulation 
and retention within a thin transparent sac, and the gradual forma- 
tion of the mass (myxomatous degeneration). Practically the same 
condition results from cystic formation due to occluded mucus-ducts 
in the glandular structures of the antral mucosa. The resulting 
tumors may be multiple, or but a single enlargement may exist. 
Pathologically, the body of each tumor shows a soft, almost liquid 
mass, which microscopically is seen to be made up of low-grade, 
irregular, soft cells, epithelial cells, some blood-corpuscles, and a 
large amount of fluid material containing considerable mucin. Their 
consistency varies from a limpid liquid to the thickness of moderately 
firm gelatin ; they may rupture and discharge through the nose, 
and refill. There is rarely any blood-supply of moment, and the 
color of the contents is usually a light amber. The symptoms of 
the condition are practically those of a confined suppuration, with- 
out, possibly, so rapid a course and without the attendant systemic 
symptom of pus-intoxication. The process may, however, be the 
means of closing the ostium maxillare, and thus favor the forma- 
tion of an empyema. The earlier stages show the symptoms of 
the existent chronic lesions, but present no evidence pointing to 
the existence of these antral growths, which, as a rule, are not 
suspected until pressure-symptoms are observed. As the antrum 
fills, however, the sense of uneasiness and heaviness in the upper 
jaw and antrum becomes marked, and pain of an aching character 
becomes prominent and more urgent as the internal pressure 
increases, which subsequently may become so great as to lead 
to extensive facial deformity on the affected side. Thinning 
of the walls occurs, a peculiar palpation-crepitus may be elicited 
at many spots, and a semi-fluctuation be obtained. Not infre- 
quently the walls may become so thin as to permit, through a rare- 
faction of the intervening tissues, the passage and extension of the 
process to an adjacent cavity. In short, all the pressure-symptoms 
of an antral empyema, without its marked acute inflammatory 
phenomena, its more rapid course, and its systemic poisoning, are 
to be noted. The symptoms of an uninfected hydrops antri are 
identical with those of mucocele. 

The diagnosis is difficult in the early stages, and often impos- 
sible. In the later periods it is perhaps not quite so uncertain, but 
is still a matter of considerable doubt. The aspiration of the antrum 
through the nasal walls will, of course, show whether the intra- 
antral pressure be due to fluid or not, but, as a rule, does not show, 



TUMORS. 383 

except by the character of the fluid, whether it be of cystic origin 
or from a simple fluid-accumulation. 

The prognosis of the condition is variable, but, as a rule, it 
is a difficult process to control. It is not a condition, however, 
notably endangering life. 

Treatment. — Generally speaking, cure may be obtained by 
draining and washing out the antrum. However, the condition 
may not be relieved by this procedure, and the cutting away of 
the outer or the nasal wall of the cavity, followed by curetment, 
may be required. The cavity should then be packed with boric- 
acid gauze until healing occurs. Some few cases have been re- 
lieved by simple puncture with the trocar and cannula. 

BONE=CYSTS OF THE ACCESSORY SINUSES. 

This condition is a cyst-like distention of the accessory sinuses 
and is a distinct and separate pathological condition and in no way 
associated with suppurative lesions of the sinuses. The pathology 
is something similar to the cystic condition of the turbinate bone. 
This cystic condition has been observed in the walls of the eth- 
moid cells and frontal sinuses and of the antrum of Highmore. 
No similar condition has been observed in the sphenoidal sinuses. 
The clinical phenomena are practically the same, regardless of the 
cavity affected. 

The course of the disease is exceedingly slow and devoid of 
acute symptoms. The swelling and displacement are very grad- 
ual, sufficiently so not to cause inflammatory lesions. The con- 
dition, then, is usually free from pain, and there is usually absence 
of tenderness on palpation. 

The origin of this cystic condition is probably found in a slow, 
chronic inflammatory process which occurs in the bony wall and 
in the lining mucous membrane of the accessory sinuses. With the 
pathological change in the wall of the sinuses an accumulation of 
mucous secretion will form in the cavity if the normal opening of 
this cavity has become occluded. This accumulation within the 
cavity may continue until there is marked thinning and absorp- 
tion of one or more of the bony walls. This absorption may con- 
tinue until the thinnest portion of the wall of the cavity breaks 
down. The character of the fluid formed is cystic or mucoid; 
it contains no pus-cells. 

TUMORS. 

Tumors of the antrum are not common. Of the benign growths, 
the myxoma and osteoma are the most common, although fibroma, 
enchondroma, and angioma have been reported. Sarcoma and 
carcinoma of the antrum may be either primary or secondary, but 



384 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

either variety will involve adjacent structure, and has been fully 
treated under Tumors of the Nose. 

Cysts and cystic degeneration occurring within the antrum are 
not uncommon. They may occur as retention-cysts, due to the 
dilatation of the follicles of the mucous membrane lining the 
cavity. Cystic degeneration may occur in the mucous membrane, 
following inflammatory processes. The so-called dentigerous cyst 
may form as a result of an inflammatory process extending from 
the root of a tooth which penetrates to the antrum, being covered 
only by the mucous membrane. 

The diagnosis can often not be made without an exploratory 
operation. 

Treatment. — The removal of cysts from the antral cavity 
may necessitate the cutting away of the outer wall of the cavity, 
in order to permit free curetment, although puncture and drainage 
should first be tried. 

PHLEGMONOUS INFLAMMATION. 

Phlegmonous inflammation of the antrum is usually associated 
with a similar condition involving the upper respiratory tract. 
The symptoms are those of an acute catarrhal inflammation 
highly exaggerated. It is rapidly fatal. Fortunately, it is an 
exceedingly rare condition. 

DISEASES OF THE ETHMOIDAL CELLS. 

a. Catarrhal Inflammation. c. Mucocele and Non-infected 

1. Acute. 2. Chronic. Fluid-retention. 

b. Suppurating Ethmoiditis. d. Specific Inflammations. 

1. Acute. 2. Chronic. e. Tumors. 

Anatomically, there are certain points in the situation and con- 
struction of these cavities that are of importance both in a consid- 
eration of their morbid processes and in the formation of diagnoses. 
It is more than probable that the ethmoidal cells are the seat of 
morbid processes far oftener than is recognized, because of a graver 
involvement in which their own symptoms are lost. The outlets of 
the anterior set of cells are in proper relationship to be bathed by 
the inflammatory or purulent discharge from the frontal or maxil- 
lary sinus ; the outlets of the posterior set are similarly related to 
the sphenoidal sinus, and both sets are by those openings liable to 
direct extension of nasal inflammation, or occlusion by turgescence 
or growths within the nasal spaces, or by their primary involvement 
to be the cause of nasal lesions. Many of the persistent and often 
fetid 'nasal discharges can be traced to lesions of the ethmoidal or 
other accessory cavities. This will explain the failure to cure many of 
the rebellious cases of rhinitis. The thinness of the investing mem- 



CATARRHAL INFLAMMATION. 



385 



brane and its close application to the bony framework are of im- 
portance in this connection, as are the thin plates of bone that form 




Fig. 157.— Horizontal section through the middle of the orbit, showing the normal 
relation of the ethmoidal cells, anterior, middle, and posterior, and the upper part of the 
nasal septum (after Cryer) : n. s., nasal septum; n.c, nasal cavities; i., infundibulum ; 
n.d., nasal duct ; 1, 2, 3, anterior ethmoidal cells ;f.o., floor of orbit ; m.e.c, middle ethmoidal 
cells ; p.e.c, posterior ethmoidal cells ; s.s., sphenoidal sinus (note difference in size of the 
two sides). 

the intercellular divisions and constitute a large amount of the 
external walls. Fig. 157 shows the position and normal rela- 
tions of the ethmoidal cells. 



CATARRHAL INFLAMMATION. 

This occurs usually as an attendant process with an acute rhi- 
nitis, and its duration and severity are directly proportionate to 
that of the principle manifestation. It may thus be either acute or 
chronic, though the latter has more of a tendency to become sup- 
purative than to remain uninfected. The acute inflammation 
may be the precursor of a suppuration, or it may subside spon- 
taneously. 

The symptoms are indefinite and ill-defined, and may be totally 
masked by those of the precedent nasal condition. When noted, 
however, they consist in a more persistent, deep-seated pain than 
would be expected from the severity of the nasal process. 

The diagnosis is not often made, and rests entirely upon the 
degree and location of the pain. The prognosis is good unless it 
precedes suppuration, as the majority of cases cease with the subsi- 

25 



386 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

dence of the nasal trouble. The treatment is directed to the relief 
of the congestion of the nasal mucous membrane and any preced- 
ing nasal trouble. 

CHRONIC HYPERPLASTIC ETHMOIDITIS. 

This condition is usually antedated by an acute rhinitis, the 
process in the nose having subsided, while the mucous membrane 
covering the ethmoid wall and outer side of the middle turbinate, 
owing to poor facilities for drainage and existing thickening from 
previous attacks, does not return to normal, but from the constant 
irritation of the secretions undergoes hyperplasia. This hyper- 
plasia spreads over the wall of the ethmoid, eventually involving 
the ethmoid cells themselves. 

The Symptoms of this condition are less pronounced than 
those of inflammation of the antrum and frontal sinus. The most 
constant is headache, frequently described as a burning or boring 
pain at the root of the nose, or it may be supra-orbital. This pain 
sometimes radiates toward the temporal region, and may simulate 
supra-orbital neuralgia. Together with the pain there is a sense 
of fulness in the eyeball, pain on reading, spots before the eyes, 
and increased secretion from the nose. The discharge is thin and 
watery, very profuse, but leaves no stain, as in the case of em- 
pyema. Owing to the increased discharge and its irritating char- 
acter there is often excoriation of the nasal alse and upper lip. 
Disturbance of the sense of smell is frequently present, or in some 
cases the sense of smell is entirely lost. Associated with this con- 
dition w r e often see asthma, pharyngitis, laryngitis, and catarrhal 
affections of the middle ear and Eustachian tube. 

The diagnosis is usually not difficult, and is made from the 
symptoms enumerated and a careful examination of the ethmoid 
region. The middle turbinate should be inspected and, if possible, 
the meatus, the bulla, and uncinate process. If there are no signs 
of polypi in this region, the mucous membrane on the outer wall 
of the middle turbinate should be palpated with a probe, and if 
this is found to be thickened and edematous it is strong evidence 
of the existence of ethmoiditis. In cases where the middle tur- 
binate lies in close contact with the outer w 7 all of the nasal cavity, 
so that it is impossible to inspect the meatus, the part should be 
cocainized and a Sinexon dilator inserted, and the blades separated 
so as to fracture the turbinate at its base and deflect it toward the 
septum. A perfect view of the meatus and ethmoid wall, together 
with the bulla and infundibulum, is now easily obtained. By this 
means we are often able to clear up an otherwise inexplainable 
chain of symptoms. 

The treatment depends largely upon the extent to which the 
condition has progressed. If polypi are present in the meatus and 



SUPPURATING ETHMOIDITIS. 387 

infundibuluin, we should not be content with removing them with 
the snare or forceps, but should discover and remove the cause. 
If there is a polypoid degeneration of the anterior portion of the 
middle turbinate this should be removed and the bulla opened. By 
means of the curet or biting forceps as much of the ethmoid 
labyrinth as is diseased should then be removed. Infraction of 
the middle turbinate is preferable to the removal of any portion 
of this bone, but where it is diseased the best results will be ob- 
tained by its removal. 

SUPPURATING ETHMOIDITIS (PURULENT ETHMOIDITIS; 
ETHMOIDAL SUPPURATION). 

Suppuration occurs in the ethmoidal cells either as an acute 
process or, in the majority of cases, as a chronic condition. It 
may follow a simple catarrhal inflammation which offers sufficient 
inflammatory swelling and exudate, either within or near the cell- 
openings, to favor the proliferation of the pus-organisms. Usually 
it is unilateral ; but it may occur on both sides, and is not infre- 
quently part of a suppurative condition present in all or most of 
the other accessory sinuses at the same time. The presence of 
any obstruction to the drainage of the cells, by nasal growths, 
swellings, or other morbid conditions, favors accumulation of 
secretion and its infection. It is apt to occur in scrofulous or 
tubercular individuals, and in the general exhibition of syphilis, 
especially of the tertiary form. Erysipelas and the acute infec- 
tious diseases, such as influenza, may precede it. It is a marked 
attendant feature of necrosis of the osseous structures in the 
immediate neighborhood, though in many cases, from a clinical 
standpoint, it may be difficult or even impossible to determine 
whether suppuration is the cause or the result. Phosphorus-poi- 
soning has been reported as causative. It may also be due to the 
presence of animate or inanimate foreign bodies. Traumatisms 
are responsible for a considerable number of the cases. Thus, a 
blow on the bridge of the nose may cause a fracture of the vomer, 
or loosen its upper attachment and expose the cells to infection. 
Similar results may follow a fall, basal fracture of the skull, or 
attend severe force in various intranasal operations, especially 
upon the septum. It may follow sutural separation. It may be 
due to infection by, or the actual invasion of, pus of a discharge 
from the frontal sinus, the antrum, sphenoid sinus, or an orbital 
abscess; and, rarely, it maybe a metastatic condition. It may, 
through occlusion, lead to a very dangerous and possibly fatal 
abscess of the sinus. 

Pathology. — There is a thickened, rough, shaggy, pus-pro- 
ducing membrane lining the cells. Later, the delicate bony 
partitions suffer, necrose, and are cast off in the purulent mass. 



388 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

In the later stages small sequestra may form. Fig. 158 shows 
destruction of the ethmoidal cells. 

The Symptoms vary. Some few cases are on record of a per- 
sistent and intractable suppuration, unattended by any symptoms 
save the discharge of pus through the nasal opening. Others run 



p 


■v * ' 


/^'T^Ik 


i 


• 38 






• jhwBK i JjM» 








w? , 


' X , , - 




^ 


' 


^j^y^p > 


p 








i 


si, 


W* 






u 



Fig. 158.— Horizontal section through the middle of the orbit, as shown in Fig. 157. 
The obliteration of the normal topography of the ethmoidal region on the right side is 
to be noticed (after Cryer). 



an acute course, show characteristic symptoms in a milder degree, 
and then cease. The majority of cases are, however, chronic, 
attended by a train of characteristic and usually severe symp- 
toms, display little tendency toward spontaneous recovery, and 
often terminate in an occlusion and filling of the cells with an 



SUPPURATING ETHMOIDITIS. 389 

increasing amount of pus. The establishment of the purulent 
process may be preceded by the usual symptoms of a severe rhi- 
nitis. Pain is present, deep-seated, and referred to the posterior 
region of the orbit or of the eyeball, or with the progress of the 
condition becomes worse, and spreads from the infra-orbital region 
to the temporal. Some observers have noted a faint blush or red- 
dening over the area of pain. There is a discharge of pus from 
the nostril of the affected side, and in cases of some standing, 
possibly with a slightly or decidedly offensive odor. It may be 
possible to increase this flow or to bring it on by external press- 
ure upon the eyeball. By nasal inspection the discharge may even 
be seen as it emerges, that from the anterior set of cells coming 
under the middle turbinal, and that from the posterior and middle 
being seen high up in the posterior part of the superior meatus. 
During recumbency it flows back into the nasopharynx, and subse- 
quently makes its way into the stomach, causing a morning nausea 
and leading to gastric disturbances. In most cases, as the dis- 
charge continues, small shreds of necrotic tissue begin to mingle 
with it, and small crumbling bits of carious bone may be found. 
The amount of the discharge may vary greatly, from a small trace 
to a profuse and almost continuous flow. In some cases a certain 
amount of retention may be noted, and yet not becoming exces- 
sive on account of its partial evacuation into the nasal chamber. 
Such conditions lead to symptoms of internal pressure, that are 
more fully observed in cases of complete occlusion. Thus, with 
the retention of the increasing amount of pus, the swelling of the 
affected cells leads to serious ocular derangements. The eyeball 
becomes bulged, reddened, and congested, the eyes watery, and 
the lids edematous. There is interference with mobility and, in 
extreme cases, even fixation of the eyeball. Diplopia occurs, or even 
blindness (see page 41 9). The sense of smell may be impaired or lost. 
The chill, irregular fever, and night-sweats of pus-absorption may 
be observed, and the general condition of the patient, both in 
health and spirits, becomes greatly depressed. Mental derange- 
ment not uncommonly is noted, and the symptoms of a meningitis 
may supervene. If the pressure continues the distention increases. 
Not uncommonly, in addition to protrusion of the eyeball, the 
swelling is noticeable as a small, smooth, increasing tumor in the 
inner angle of the orbit of the affected side, with the added phe- 
nomena of a severe inflammation. With the attainment of extreme 
distention, thinning of the restraining tissue is quickly followed by 
the rupture and discharge of the confined pus, weeks, months, or 
it may be years after the establishment of the suppurative process. 
The evacuation of the pus may occur in several directions. It 
may open through the inner angle of the orbit and precede a 
stubborn fistulous formation. It may give rise to a severe orbital 



390 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

abscess and a suppurative panophthalmitis; and it may even 
open into the antrum, the frontal sinus, or the nasal chamber, 
or else it may spread to other adjacent parts by direct communi- 
cation. With alarming frequency it opens into the anterior fossa 
of the skull, and leads to a rapidly fatal suppurative meningitis. 
Following the evacuation of the pus there is relief of the urgent 
symptoms, succeeded in turn by an obstinate fistula, the ultimate 
destruction of the eye on the affected side, or the rapidly fatal 
termination of a suppurative meningitis or encephalitis. 

The diagnosis in a well-marked uncomplicated case is not 
difficult, and is made upon the symptoms enumerated. The occur- 
rence of suppurative conditions in the remaining sinuses at the 
same time is a feature causative of some confusion. The site of 
the pain, the nature of the ocular manifestations, the character of 
the nasal discharge, and the presence of bits of carious and necrosed 
bone are of value in a differential diagnosis. Transillumination 
may be of value, and in the later stages of bone-sloughing it may 
be possible to elicit a grating or crumbling sensation by passing a 
probe through the nose and over the affected area. 

The prognosis is grave. The disease may run a course of 
weeks, months, or even years, and stop, in rare instances, spon- 
taneously. It is very stubborn and intractable to treatment, and 
while active remains a steady and dangerous menace to the life 
of the patient. 

The complications of suppurative ethmoiditis are usually 
due to an extension of the infection through the lamina papyracea, 
the thin plate of bone separating the ethmoidal cells from the 
orbit, which is often defective in its formation. The most common 
form of complication is external rupture with the formation of a 
fistula, the usual site being the upper and inner angle of the eye. 
The infection, after having penetrated the lamina papyracea, gen- 
erally meets with considerable resistance on the part of the orbital 
periosteum, and selects the line of least resistance, burrowing under 
the periosteum until it reaches the region of the ethmolacrimal 
suture, where it ruptures externally. The fact that external rup- 
ture occurs more frequently than involvement of the orbital struc- 
tures is largely due to the strong resistance offered by the orbital 
periosteum. Occasionally, however, this resistance is overcome, 
and the infection penetrates the periosteum and an orbital abscess 
results. On the other hand, infection of the orbital cavity may 
occur by the transmission of the infection through the ethmoidal 
veins, without perforation of the lamina papyracea. Of the intra- 
cranial complications following suppurative ethmoiditis, meningitis, 
brain abscess, and thrombosis of the cavernous sinus are the most 
common. Infection of the cranial cavity may result from direct 
extension through the cribriform plate, or indirectly through the 



SUPPURATING ETHM0ID1TIS. 391 

ethmoidal veins, which anastomose freely with those of the dura 
in this region. Thrombosis of the cavernous sinus results from 
infection of the ethmoidal veins, which empty into the ophthalmic 
and these in turn into the cavernous sinus. 

Treatment. — The treatment of ethmoidal suppuration depends 
largely upon the extent and situation of the disease ; that is, 
whether or not all the cells are involved. In the majority of 
cases suppuration in the ethmoidal cells will necessitate operative 
interference, although in some cases where there is free drainage 
established, owing to the anatomical relations, the cells can be 
syringed out and afterward thoroughly dried by means of hot air, 
and operative interference will not be necessary. These cases, 
however, are few in number. The treatment then can be divided 
into practically two classes : first, cases in which the cells can be 
reached by the intranasal method, and under local anesthesia the 
ethmoidal cells can be opened, curetted, and drained ; and, second, 
the external operation in which general anesthesia is used. In 
the intranasal method, in nasal obstruction such as hyperplasia of 
the turbinates, the new growths must be removed together with 
the anterior end of the middle turbinate bone. This clears the 
approach to the middle anterior ethmoidal region. It is well to 
allow this operative interference to entirely heal before attempting 
to open the ethmoidal cells. If, however, it is a discharging sup- 
purative process and not confined suppuration, the operation can 
be completed at one setting. After complete anesthesia the 
affected cells may be opened with a sharp curved hook, such as 
that of Hajek, and a portion of the wall subsequently cut away 
by means of the Grunwald or some similar forceps. When the 
cells are once opened it is well to determine how much necrosis 
and destruction of tissue has taken place. If it is merely an in- 
fection of the mucous membrane lining with no necrosis, it is not 
necessary to curet, but free drainage should be established and 
the parts thoroughly cleansed. If, however, there is necrosis, 
then free curetment should be made. The ring-knife curet sini- 



f&2£ 



Fig. 159.— Bryan's ethmoid curet. 



ilar to that of Myles (Fig. 144) and Bryan's combined gouge and 
curet (Fig. 159) are the best instruments for this purpose. Great 
care should be taken in cureting to use no force upward for fear 
of injuring the cribriform plate. With a sharp ring-knife thor- 
ough curetment can be made with the use of very little force. 
The after-treatment in these cases consists in washing out and 
drying the cavity, and keeping it as sterile as possible. After the 



392 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

first twenty-four hours if there be any sign of discharge, the nose 
should be frequently irrigated with an alkaline antiseptic solution, 
such as that given on page 135. With conditions necessitating 
the external operation there is usually associated suppuration of 
the ethmoidal cells — an orbital abscess-^and usually accompanied 
by cerebral symptoms. Thus, it is rarely, if ever, necessary to do 
the external operation for ethmoid disease unless it is associated 
with some other lesion, such as orbital abscess. The operation is 
somewhat similar to that employed for disease of the frontal sinus. 
Incision is made commencing near the supra-orbital notch, just 
below the supra-orbital margin, curving downward and inward 
and ending somewhat below the inner canthus. This incision is 
carried down to the bone, and the periosteum is carried farther 
back along the inner wall of the orbit. The incision will have to 
be carried down almost on a line with the lowest point of the in- 
ferior orbital ridge. However, if the abscess of the orbit is asso- 
ciated with suppuration of the ethmoidal cells a sinus will usually 
exist and can be traced by the grooved director or small probe.. 
Whatever the course of the sinus may be, the bone should be cut 
away and the sinus followed and opened directly into the eth- 
moidal cells. Every portion of disease and infected tissue should 
be carefully cut and curetted away, followed by the usual anti- 
septic dressing as employed in any wound. In the majority of 
cases it will necessitate packing with iodoform or boracic-acid 
gauze for several days ; however, if all the infected tissue can be 
removed during the operation, drainage can be established through 
the nostril and the wound closed and dressed with antiseptic 
dressings. It is difficult, however, to obtain perfect union by 
first intention, there being in the majority of cases some point of 
slipping, which will require the most careful attention. 

MUCOCELE AND NON=INFECTED FLUID=RETENTION. 

This condition is of comparatively rare occurrence in the eth- 
moidal cells, and when so situated presents the same etiological 
and pathological conditions that have been noted in its exist- 
ence in the other accessory sinuses. The peculiar symptoms 
are usually ill-defined, and may entirely escape recognition 
because of their lack of prominence and severity. The symptoms 
of the chronic inflammatory process, which is precedent to the 
development of the myxomatous growths or degenerative proc- 
esses, are, of course, to be noted. Beyond this, however, but lit- 
tle can be said. In the late stages, pressure-symptoms may be 
observed to a moderate degree. There may be external deformity 
and eye-symptoms through pressure on the orbit. The diagnosis 
is difficult, often not made, and may require an extended observa- 



TUMORS. 393 

tion of the case before being arrived at. The prognosis is not 
unfavorable. 

The treatment consists in cnretment and thorough evacuation 
of the contents, with daily flushing out of the cavity until healing 
takes place. 

SPECIFIC INFLAMMATIONS. 

Syphilis, Tuberculosis, and Actinomycosis. 

Syphilis, tuberculosis, glanders, actinomycosis, and the acute 
infectious diseases all may involve the ethmoidal sinuses in their 
occurrence or enter into the etiology of some of the morbid proc- 
esses occurring there. Such involvement is a dangerous com- 
plication of these conditions, and may be the fatal factor in a case 
otherwise of favorable outlook. The symptoms may or may not 
be of localizing value, and the diagnosis, in connection with the 
more general symptoms of the disease, is proportionately difficult. 
The prognosis is unfavorable in the majority of instances, both 
because of the disease-extension itself and the dangers of a result- 
ant suppuration. Local treatment is of little or no curative avail, 
and remedial measures must be directed to the primary process. 

TUMORS. 

New growths are of rare occurrence in the ethmoidal cells. Of 
the non-malignant type, myxomata are perhaps the more commonly 
found, while osteomata occasionally occur and tend to involve or 
encroach upon the orbital cavity. Fibroma is a rare growth. 
These may remain quiescent and be totally unsuspected for a long 
period of time. They may grow slowly and, by a painless increase 
in size, lead to external symptoms denoting filling of the sinuses, 
with distention and possible perforation of their walls. As a 
rule, they are not dangerous, save as encroaching on neighboring 
structures or perforating into adjoining cavities. The tendency of 
all benign growths to become the site of malignant change in 
certain cases is a feature meriting note in a prognostic view. The 
treatment, if they pass beyond the limits of safety, is removal, of 
course, though it is impossible, from the varied conditions of each 
case, to lay down rales of technic for procedures which, in a given 
case, may be impracticable or of impossible performance. Sarco- 
mata and carcinomata have been noted, usually as a secondary 
involvement, and more rarely as primary processes. Unfortunately, 
they are not, as a rule, discovered until the morbid condition has 
progressed to an unfavorable and inoperable stage. Such cases 
can be treated only by local antiseptics and the use of general or 
local anodvne measures. 



394 DISEASES OF THE ANTERIOR NASAL CA VITIES. 

DISEASES OF THE SPHENOIDAL SINUSES. 

1. Catarrhal Inflammation j jj* Chronic 

{a. Acute. 
b. Chronic, 
c. Confined. 

3. Tumors. 

4. Syphilis, Tuberculosis, and Acute Infections. 

5. Mucocele. 

Morbid processes of the sphenoidal cavities, as a rule, are of 
difficult diagnosis. Related as are the other sinuses to the nasal 
spaces by direct open communication and continuity of investing 
membrane, they are thus liable to the development of pathological 
conditions by direct introduction of irritative material through 
continuity of structure. So far as our knowledge goes, they are 
rarely affected without either a precedent or concomitant disease of 
the other sinuses or the nasal region, and for this reason their 
peculiar symptoms are obscure, unless well marked among the 
more patent manifestations. Their deep situation, as well as the 
difficulty or impossibility, except in rare cases, of obtaining a view 
of the site of their outlet, is another feature of note in this con- 
nection. Both cavities may be implicated simultaneously, but in 
the majority of cases the affection is unilateral. 

CATARRHAL INFLAMMATION. 

Usually this occurs as an extension of an inflammatory process 
from the nose or nasopharynx, or attends an inflammatory process 
in an adjacent structure. It may be acute or chronic, and may 
lead to retention of inflammatory exudate, to degenerative changes, 
or to suppuration. The symptoms are not well defined, nor dis- 
tinctive in their character. There is a sense of weight and fulness 
deep in the middle region of the head, in addition to a vague sense 
of occipital distress, a dull headache, or possibly pain referred to 
part, or perhaps all, of the distribution of the trigeminal nerve. 
Dull pain may be felt in the deepest part of the orbit of the 
affected side, and in some cases ocular symptoms may occur. There 
is more or less of a discharge of mucus, either in a continuous 
flow or at intervals, the tendency being for its postnasal escape. 
This may lead to some collection of inspissated secretion in the 
upper and posterior part of the nasal space. The diagnosis is not 
easy, and is often not made at all, unless special symptoms become 
more pronounced than are proportionate to the primary condition. 
The prognosis of the uncomplicated acute catarrhal process is 
excellent. However, it may be of grave import in that both acute 
and, more especially, chronic catarrhal processes are apt to become 



EMPYEMA OF THE SPHENOIDAL SINUS. 395 

the initial stage of a suppurative or other morbid process, which 
not unlikely may prove fatal. 

The treatment is that appropriate to the existent nasal lesion, 
carried out with scrupulous care as to its antiseptic aspect. 

EMPYEMA OF THE SPHENOIDAL SINUS. 

As before, the existence of a purulent condition in neighbor- 
ing cavities, either of the nose or its connected sinuses, is a pri- 
mary etiological factor. It may follow direct infection through 
the inlet of the sinus, or be a secondary infection following the 
rupture into it of pus from an ethmoidal empyema. Compound 
fractures and operative or other rarer traumatisms may be respon- 
sible for its origin. Syphilis, tuberculosis, and the acute infec- 
tious diseases may not infrequently precede or accompany it. It 
attends necrosis of the bony structures, and is not unlikely to 
accompany and severely complicate a tubercular meningitis. 
Usually it is of one side, though both may be simultaneously 
involved ; it occurs as an acute process or as a chronic condition, 
and in either form may lead to a dangerous confined suppuration. 
Its location is markedly aided by structural or pathological con- 
ditions favoring retention of the inflammatory secretion, and a cer- 
tain proportion of cases originate as an infection of a seromucous 
accumulation in the sphenoidal space. 

The symptoms vary much in severity in the acute form. 
Pain is variable both in its site and character. There may be a 
dull, diffuse headache, scarcely more than annoying, or it may be 
sharp, localized, and neuralgic. The pain may be referred to the 
distribution of the supra- or infra-orbital nerves or both, or may, 
especially in accumulation of pent-up fluid, excite neuralgic pain 
referred to the entire distribution of the fifth nerve of the affected 
side. It may be constant or remittent. There is more or less of 
a purulent discharge, thin or of a fairly thick consistency, with a 
more or less fetid odor, and, in the later stages, it may contain 
small bits of bone. This discharge may be observed under favor- 
able circumstances at the upper and posterior part of the nasal 
space, as the outlet of the sphenoidal sinus is just above the poste- 
rior end of the middle turbinate, and it shows a tendency to escape 
into the nasopharynx. Not infrequently it is mingled in a com- 
mon discharge with pus from the ethmoidal cells, and may in the 
recumbent position accumulate in the nasopharynx and produce a 
morning nausea or gastric disturbance. Annoying and persistent 
tinnitus aiwium may be present, and even vertigo may occur. 
These symptoms may exist for some time and then gradually sub- 
side, or, more commonly, continue with varying intensity, mark- 
ing the existence of the chronic condition. In either case they 
intensify with the establishment of a confined suppuration. 



396 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

There is in the chronic type little variation in the character of 
the symptoms already noted, with, however, more of a toler- 
ance of the pain on the patient's part. Exacerbations occur, 
due largely to temporary retention of fluid. The discharge is 
more or less profuse, shows more of a fetid tendency, and may 
later contain crumbling bone. The mental condition is one of 
hebetude, the eyes are heavy, and there is a general languor. Sleep 
is imperfect and not refreshing. The stomach becomes disordered, 
and the breath sour and heavy. The patient is depressed, and 
shuns company ; the whole system shows the cachexia of a sup- 
purative drain. The tinnitus is more persistent and severe, and 
not uncommonly may lead to a temporary loss of hearing on the 
affected side. Attacks of vertigo may occur. 

The symptoms of suppuration with the drainage of the resultant 
pus are, however, mild compared with those that ensue upon its con- 
finement. The usual obstructive causes that have been noted in the 
pus-collections of the other sinuses are equally operative here. There 
is a lessening of the purulent discharge, with retention of the greater 
bulk, or the cessation may be complete. The pain intensifies, is 
more constant, and begins to show locally the deep-seated, heavy, 
throbbing character of abscess-formation. Sleep is impossible 
without hypnotics. The systemic evidences of pus-formation are 
shown in the development of irregular fever, sweats, and the usual 
correlated manifestations, with the attendant systemic weakening. 
Cerebral symptoms may supervene from the extension of inflam- 
mation by contiguity. With the increasing internal pressure, 
peculiar ocular symptoms develop, such as photophobia with pro= 
fuse watery discharge from the eye, and turgescence of the lids 
and the conjunctiva. With increasing distention, pressure upon 
the optic nerve leads to a progressive lessening of the field of 
vision, which in the majority of cases begins peripherally. Sco- 
toma is not unlikely to occur, and even total blindness may result. 
Ophthalmoscopic examination shows the typical choked disk of an 
optic - neuritis. The swelling continuing, the eyeball shows re- 
stricted motion ; strabismus, blepharospasm, or, later, ptosis takes 
place, and finally the ball may be shoved forward in a marked 
exophthalmos. The ear-symptoms are intensified — associated 
with almost continuous dizziness — in the upright position, attended 
with nausea and vomiting even compelling the maintenance of the 
prone position. 

The nasal spaces may be closed by the swelling. The suffer- 
ings of this stage may be extreme and may cause delirium. Un- 
less relieved, thinning of the walls of the sinus takes place, followed 
by rupture at a weakened point and discharge of the restrained 
accumulation, with relief of the urgent symptoms. Eupture may 
take place into the orbit and establish a destructive orbital abscess 



EMPYEMA OF THE SPHENOIDAL SINUS. 397 

and, secondarily, invade the skull. It may break through the 
skull above, and set up a rapidly fatal suppurative meningitis, or 
lead to a suppuration of the cavernous sinus (sinus thrombosis), 
with all the morbid possibilities that such an infection would 
entail. The process may invade the ethmoidal cells, or it may find 
vent into the nose or nasopharynx. 

The diagnosis in the earlier stages may be very difficult or 
indeed impossible. Its occurrence with suppurative disorders of 
the nasal cavities or of the remaining accessory sinuses, with their 
own localizing and general symptoms, taken in connection with 
the difficulty of access to the sphenoidal region, even by posterior 
rhinoscopy, may totally obscure the involvement of the sphenoidal 
region. 

Thornwaldt's disease, or suppuration of the pharyngeal bursa, 
is rare, but may in some cases cause confusion. In a number of 
instances, the sphenoidal symptoms may be sufficiently marked to 
permit a diagnosis by exclusion. 

The prognosis is very grave. In rare instances the acute 
form subsides spontaneously, but more frequently becomes chronic 
or confined. The cerebral and orbital dangers of the process have 
already been mentioned, and here need but reference to their usu- 
ally fatal significance. Early in some cases it may be possible, 
through proper surgery, to remedy the condition. 

Treatment. — The treatment should consist in the allaying of 
nasal inflammation by the use of a detergent and antiseptic spray 
such as — 

Ifc. Potassii bicarbonatis, 
Sodii biboratis, 

Sodii chloratis, da gr. v (0.3) ; 

A^cidi carbolici, Tttiij (0.18) ; 

^qua3, fl^j (30.).— M. 

Nasal irregularities should be corrected. For opening the 
sphenoidal cells a sharp gouge should be used, or an instrument 
of similar construction. This should be introduced through the 
nose, carefully following the upper border of the middle turbinated 
body. The point of the instrument, if pushed backward and 
upward, will penetrate the sphenoidal cells at the most dependent 
portion. Great care should be exercised in entering the sphenoidal 
cells, owing to their proximity to the cranial cavity, which might 
be entered if too much force is used. The direction of the instru- 
ment may be better guided if the operation is done with the aid 
of posterior rhinoscopy. When the sphenoidal cells are reached 
and the pus allowed to escape, the cavity should be gently curetted 
for the removal of caseous material or necrosed bone. The grav- 
ity of surgical operations on the sphenoidal cells cannot be over- 



398 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

estimated , owing to their close relation to the cranial cavity, and 
the diseased process may have so weakened the wall as to permit 
of easy penetration into that cavity. The sudden relief of the con- 
fined fluid often brings on dangerous syncope. After opening the 
sphenoidal cavity, it should be washed out with a tepid boric-acid 
solution, 8 grains to the ounce of water, to each ounce of which 
should be added 5 drops of carbolic acid. Equally good results 
may be obtained by washing out the cavity with a 10 to 20 
per cent, argyrol solution. 

The sphenoidal cells are not so difficult to open as some are 
inclined to think. In cases where the septum is moderately 
straight and where the posterior portion of the middle turbinated 
bone has been removed, the oozing pus can be easily detected at 
the point of the natural opening, high up and near the septum. 
The probe will often enter after careful use ; a small, sharp, firm 
curet passed in and then pulled outward will usually tear away 
the sides of the opening sufficiently for good drainage. I do not 
consider it safe to curet the upper and external walls of these 
sinuses. Careful scraping of the anterior wall and the floor often 
produces decidedly beneficial results. 

TUMORS. 

Of the benign tumors, myxomata and osteomata are noted as 
occurring in this location. They are usually small, may be qui- 
escent or grow slowly, but steadily, and invade surrounding 
structures. They may be absolutely without symptoms, excite a 
catarrhal inflammation, or through obstructive tendencies favor 
suppuration. In the later stages, severe pressure-symptoms may 
be observed — exophthalmos, and perversions of mobility of the 
eyeball, and optic neuritis or blindnes due to pressure on the optic 
nerve. Their presence is nearly always unsuspected until they 
reach a size sufficient to exert pressure ; their treatment should be, 
of course, removal. This, however, is frequently an impossible 
procedure. The tendency of benign growths to become the site of 
malignancy is a feature to be recalled in the prognosis. Carcinoma 
and sarcoma occur as secondary processes or, rarely, as primary 
growths. Unfortunately, they are inoperable, and doom the patient 
to an early death. 



SYPHILIS, TUBERCULOSIS, AND ACUTE INFECTIONS. 

Syphilis, tuberculosis, and the acute infectious diseases may 
occur, often unrecognized ; and, when so occurring, they need no 
further mention than to call attention to the dangerous complica- 
tion they entail to the original condition. 



ACUTE CATARRHAL INFLAMMATION. 399 



MUCOCELE. 

This occurs under precisely the same conditions that favor it 
in the other accessory sinuses. The symptoms are indefinite, gen- 
erally unrecognizable, and may be confined to pressure-symptoms 
of the orbit and eyeball. Uninfected fluid-accumulation is rare, 
and symptomatically identical. Both are liable to be followed by 
suppuration, and in this light are of somewhat doubtful prognosis. 

DISEASES OF THE FRONTAL SINUS. 

1. Acute Catarrhal Inflammation. 

2. Chronic Catarrhal Inflammation. 

3. Empyema. 

a. Acute Purulent Inflammation. 

b. Chronic Purulent Inflammation, 

c. Confined Suppuration. 

4. Mucocele. 

5. Foreign Bodies. 

6. Infectious Conditions. 

7. Tumors. 

ACUTE CATARRHAL INFLAMMATION. 

Catarrhal inflammation of the membrane lining the frontal 
sinus is by no means a rare complication of inflammatory condi- 
tions of the nasal mucosa. Rarely does it occur alone in these 
cavities, and as the development of the frontal sinus is not com- 
plete before the twentieth year, its occurrence, or that of any other 
morbid process of this location, is not to be anticipated prior to 
that age. Catarrhal conditions are more often observed than, sup- 
purative, a fact easily explained by the smaller size of the frontal 
cavities and the long and dependent channel leading from each, 
with its free natural drainage. Usually the condition arises as an 
extension of an acute rhinitis or a sequel of a more chronic condi- 
tion, the etiological factors of which, without repetition here, become 
of causative import in the further extension. Any cause occlud- 
ing the outlet from the sinus is of marked etiological bearing. It 
is frequently a complication or an after-effect of la grippe. Trau- 
matisms, the existence of a scrofulous diathesis, specific taint, the 
presence of certain tumors in the cavities, foreign bodies, too 
strong nasal douching, and certain ill-understood gastro-intestinal 
lesions all stand in a causal relation to the disease. The acute 
form may be the initial stage of a chronic condition, or may be 
precedent to suppuration. 

Pathologically, the usual phenomena of acute catarrhal proc- 
esses of the mucous membranes are to be observed. 

The symptoms of the condition may be so slight as to be 
almost, if not quite, masked by those of the primary inflammation, 
or may be so severe and localized as to make the symptoms of the 



400 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

latter mild in comparison. Pain is a prominent symptom, and 
may occur before, during, or after the nasal manifestation. It 
may be unilateral or bilateral, as one or, as is usually the case, 
both of the cavities are involved. The pain may be severe, 
heavy and aching, or sharp and neuralgic, and is confined to the 
frontal region. It is made worse by coughing, by the use of 
strong heart-stimulants, by blowing the nose, and by bending the 
head forward. There is a sense of weight and fulness in the fore- 
head, especially over the frontal prominences and between the 
eyes, and this in .turn may grow progressively worse, or be relieved 
somewhat by a discharge of mucus into the nostril. Various 
causes are assigned for the pain-production, notably unequal air- 
pressure through tumefaction of the membrane related to the 
frontal canal or, again, the pressure of the swollen and actively 
secreting membrane of the sinus itself. There is marked tender- 
ness of the supraciliary regions, especially over the course of the 
supra-orbital nerves. Reflex eye-symptoms are prominent, such 
as conjunctival or palpebral congestion, photophobia, and exces- 
sive lacrimation, and there may be some peri-ocular edema. Nau- 
sea and vomiting are not uncommon. Nasal inspection offers 
nothing of value except the signs of the existent nasal lesions. 

The diagnosis is usually not difficult, and is based upon the 
principal localizing symptoms given, with the existence of an 
inflammatory condition of the nose. The prognosis is good, as the 
disease usually subsides with the cessation of the nasal trouble. It 
may cease suddenly, usually after the discharge of a considerable 
amount of thin mucus from the nostril. It may, however, go on 
to the chronic type of inflammation, or become suppurative — con- 
ditions dependent upon the continued presence of the exciting 
cause and the addition of infection. 

Treatment. — The treatment consists first in looking carefully 
into the condition of the nasal cavity, correcting any obstruction 
or lesion that would lead to inflammatory processes. Cocain in 4 
per cent, solution sprayed into the nose, or applications of similar 
strength on a cotton-covered probe, will often relieve the congestion. 
The effect of this will be heightened and prolonged by the addition 
of aqueous extract of suprarenal gland. Heat should be applied 
in the form of hot-water douches as well as externally. The inter- 
nal nasal application of the hot- water douche should be continued 
from five to ten minutes every two or three hours. Instead of 
hot water, a very soothing effect can be obtained by the use of 
hot milk at a temperature which can be comfortably borne by the 
patient; to each ounce of this solution should be added 3 grains of 
sodium chlorid. Internally, there should be administered a brisk 
mercurial cathartic, followed by a saline. If the pain is excessive 
and demands special treatment, the internal administration of a 
pill containing — 



CHRONIC CATARRHAL INFLAMMATION. 401 

1^. Extracti belladonna?, gr. \ (.007) ; 

Camphorse, gr. -J- (.03) ; 

Quininse bromidi, gr. -| (.03) ; 

every hour for three doses will usually give relief. Any idiosyn- 
crasy to the action of the belladonna should be carefully noted. 
Equally good results can be obtained by a pill containing \ grain 
of camphor to \ to \ grain of codein administered every two hours 
for from two to four doses. A warm bath, followed by a hot 
lemonade and a 5-grain Dover's powder early in the attack, will 
often entirely arrest or at least shorten the attack. 

CHRONIC CATARRHAL INFLAMMATION. 

This arises as a continuation of an acute inflammation or as 
the result of repeated acute attacks, and its existence depends 
upon the recurrence or continued presence of the irritative cause, 
prominent among which stand intermittent or protracted nasal 
obstructions to the frontal canal, as from a turgescence of the 
nasal membrane near the exit of the canal, obstruction by polypi 
or other growths which lead to the retention of an unnatural 
and irritating amount of secretion from the sinus itself. Sim- 
ilarly, the presence of certain tumors within the cavity of the 
sinuses, foreign bodies, however introduced, or the retention of 
strong solutions from a nasal douche may provoke it. This form 
not uncommonly leads to a retention of seromucous material within 
the cavities, or to a mucoid degeneration of the investing mem- 
brane, with the formation of mucous cysts, or myxomatous growth, 
filling the chamber and constituting a condition known as muco- 
cele, the symptoms of both conditions being identical. Pathologi- 
cally, the membrane shows an irregular thickening and roughen- 
ing, and may be granular, as in any chronic catarrhal disorder, or, 
in the later stage, show evidences of myxomatous proliferation. 
The attendant symptoms are in a great measure identical with 
those noted in a simple catarrhal attack. There is, however, this 
difference, that the pain is more constant, with frequent and severe 
exacerbations. The dulness and weight may become very marked, 
with the retention and accumulation of secretion in the cavities, 
and be greatly relieved by its discharge, and this may occur 
at fairly definite intervals. All the pain-symptoms are aggra- 
vated by inclining the head forward, by coughing, or by blowing 
the nose. Eye-symptoms are present, but usually are of less 
degree than in the acute form. Tenderness over the cavities and 
over the sites mentioned in the acute variety is to be noted in the 
chronic form as well, and should considerable accumulation of 
fluid take place, this becomes marked, and a slight but notice- 
able bulging may be noted near the inner angle of the orbit of the 

26 



402 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

affected side. A prominent symptom is the occurrence at irregular 
intervals of a discharge into the nostril of a varying amount of 
clear mucoserous fluid, attended by marked relief of the pain and 
tenderness in the frontal region. 

The diagnosis is usually not difficult, and is made on the 
frontal symptoms, the coexistence of a nasal lesion as revealed 
by rhinoscopy, and upon the irregular discharge into the nostril 
of the contents of the cavity, with attendant relief of the frontal 
distress. 

The prognosis is good, as a rule. Suppuration may super- 
vene, and the distention which may follow a catarrhal secretion 
without vent, or suppuration occurring under the same circum- 
stances, must modify the prognosis, in view of possible cerebral 
sequelse or fistulous formation. 

Treatment. — Chronic inflammatory processes involving the 
frontal sinus are most frequently associated with the same condi- 
tion involving the nasal mucosa. The first plan of treatment, 
then, should be directed toward the existing associated lesion, as 
given in the special chapters for such lesions. Any astringent and 
antiseptic cleansing solutions employed should never be cold, but 
at a temperature that can be comfortably borne by the patient. 
The application of ichthyol is highly beneficial. A pledget of 
cotton should be saturated with a 15 to 40 per cent, solution, the 
strength being adapted to each individual case. The pledget 
should be placed high up in the nasal tract and allowed to remain 
from one-half to two hours. This should be repeated every day 
until amelioration of the inflammatory phenomena occurs. Equally 
good results can be obtained by the application in the same man- 
ner of carbolized vaselin, to which has been added 6 grains of 
alum or 4 grains of tannic acid to the ounce. There is, however, 
a marked tendency for the chronic inflammatory process to become 
infected. The treatment then will necessarily be the same as that 
given under Empyema or Suppurative Conditions of the Frontal 
Sinus. 

EMPYEMA OF THE FRONTAL 5INUS. 

Acute Pueulent Inflammation. 

This may occur at any time during the existence of the acute 
or chronic catarrhal inflammation, or may be an original inflam- 
mation of the frontal sinus. Suppuration is not common in these 
cavities, probably because of the free drainage they usually have. 
Infection may take place in one sinus or in both ; it may occur 
from within or, more rarely, from without the nasal cavities ; and 
it is reasonable to suppose a sufficient degree of obstruction present 
from inflammatory phenomena to favor the lodgement and prolif- 
eration of the pyogenic organisms. The nasal douche may be the 



EMPYEMA OF THE FRONTAL SIX US. 403 

carrier ; it may be forced up in inflation of the middle ear or by 
violently blowing the nose ; it may be rarely carried up by insects 
or, more rarely still, be a metastatic process. Diphtheria or ery- 
sipelas may precede its development. Compound fractures and 
traumatisms, external and internal, may be the means of admitting 
it, and it may follow bone-necrosis. In many cases it is impossible 
to determine the mode of infection. The predisposing elements 
that were noted in the etiology of the catarrhal malady are equally 
of force here, especially the diathetic strain of tuberculosis. 

The symptoms are in general those of catarrhal inflamma- 
tion exhibited in greater intensity. The pain is sharper, with 
more of a tendency to a beating and throbbing character, and it 
may even be mistaken for neuralgia. There is also an intermittent 
or continuous discharge of a bright-yellow, sometimes offensive 
pus from the nostril of the affected side. This needs to be differ- 
entiated from that coming from the antrum, and not infrequently 
it is mingled with pus from the latter source in a common dis- 
charge. The localizing symptoms, of course, must be taken into 
account, as well as the fact that inversion of the head favors the 
antral evacuation and retards that' from the frontal sinuses. It 
may be difficult in some cases to differentiate the discharge from 
the purulent exhibition of ethmoidal disease ; so that the diagnosis 
is sometimes attended with difficulty, especially at the first exam- 
ination of the case, and it may be masked a long while by the 
symptoms of a suppuration from the other accessory sinuses. The 
local symptoms, the observance of pus beneath the middle turbinal, 
which, unlike that from the antrum, does not recur with the head 




Fig. 160.— Electric illuminator for frontal sinus. 

in the inverted position, are the main diagnostic points. Trans- 
illumination is of possible value both in the direct and differential 
diagnosis. 

The lamp, hooded as shown in Fig. 160, or protected by a rubber 
tube, is placed in the angle between the nose and the eyebrows 
and directed upward. The emptying of the cavity by drainage 
renders this means of diagnosis of little avail, except in confined 
cases. Transillumination through the mouth is of doubtful value 
for the same reason, with the added objection that anatomical con- 



404 DISEASES OF THE ANTERIOR NASAL CAVITIES. 



ditions of the frontal sinus, or the nasal chamber, or ethmoidal 
cells will vitiate the findings. 

The prognosis is uncertain. Many cases run a course even 
of several weeks, and then cease spontaneously. Others termi- 
nate in a stubborn and intractable chronic suppuration, while still 
others early in their course, or it may be after a chronic condition 
has developed, through loss of drainage by some occlusion of exit, 
lead to an accumulation of pus within the sinuses, that may be 
very disastrous in its result. There is little danger to life except 
in the latter condition, which, if not relieved, is of grave import 
in its cerebral relation. 

The complications of acute purulent inflammation of the fron- 
tal sinus are rare, when compared with the chronic form, and are 
usually due to a direct extension of the infection through the perfor- 
ating veins. Periostitis and ostitis are probably the most common 
complications. Caries and necrosis of the bony walls of the sinus 
must be considered very rare, although they do occasionally occur, 
resulting in various orbital and intracranial lesions. However, the 
intracranial complications are generally due to the infection being 
transmitted directly to the meninges through the perforating veins." 
Osteomyelitis occasionally occurs and may be either circumscribed 
or diffuse. 

Chronic Suppurative Inflammation (Chronic Purulent 

Inflammation) . 

This occurs either as a sequence of an acute suppuration or 
as the result of repeated attacks. The persistence of the infec- 
tion is dependent upon the continuance of an exciting cause 
and the maintenance of sufficient obstruction in the sinus-out- 
lets to prevent free drainage. Thus, the inflammation may be 
kept up by the presence of a tumor within the sinus, the irrita- 
tion of a foreign body, carious bone, insects or worms, or of 
smaller objects washed in by a douche or introduced by trauma- 
tism. The retention of the purulent fluid is in itself a very active 
means of prolonging its production. Thus it is that some cases 
of suppuration occur, particularly if the result of traumatism, 
which progress slowly, give rise to no severe or marked symptoms, 
and indeed are very ill-defined before accumulation of pus begins 
to show itself in the systemic and local manifestations of an 
abscess. Necrotic conditions involving the neighborhood of the 
sinuses, whether local or systemic, as of tertiary syphilis, are 
attended by it. The occlusion of the outlets may be caused by 
the swelling of a hyperplastic rhinitis or by the existence of nasal 
polypi, and is a considerable factor in the maintenance of the 
process. Not rarely it may be so complete as to preclude pus- 



EMPYEMA OF THE FRONTAL SINUS. 405 

exit at all, and lead to its dangerous retention within the frontal 
chambers. 

The pathological picture is that of a thickened and rough, 
shaggy, pyogenic membrane covered with yellow and possibly 
fetid pus. 

The symptoms are but modifications of those observed in the 
catarrhal involvement. The pain may become of a dull, constant, 
aching character, with severe exacerbations either in damp Aveather, 
on access of nasal inflammations, or on taking cold, or it may 
be sharp and neuralgic. There may be a periodic tendency 
noted, marked by the gradual increase of all the symptoms, until 
almost unbearable, and then attended by a gradual relief, as the 
evacuation of the retained pus occurs. Reflex disturbances of 
the eye are commonly noted, and are proportionate in severity to 
the other symptoms observed. The patient's general mental con- 
dition is apt to become impaired, and he becomes apathetic, for- 
getful, and unable to attend to business, and generally depressed 
in a degree commensurate with the duration and severity of the 
process. There may in some cases be observed the same aversion 
to society that has been already mentioned in connection with condi- 
tions attended by more or less offensive odor. The discharge from 
the sinus affected may be constant or, as more frequently occurs, 
periodic. In amount it may be slight or profuse and of a decided 
yellow tint. It may be possible to observe its collection under the 
middle turbinated bone of the affected side, though the possibility 
of admixture from other sources should not be forgotten. Polypi, 
edema, and the like should be noted in this region in their causa- 
tive relationship. 

The diagnosis is usually not of difficulty, although, as in the 
acute form, it may require a more or less extended observation 
before it is determined. It may be necessary to make it by the 
exclusion of other manifestations, though this is rarely the case* 
Transillumination may give confirmatory diagnostic data. 

The prognosis is not favorable for a spontaneous cure, and in 
any case depends upon the ability of the physician or surgeon to 
ascertain and remove the exciting causes. Should a confinement 
of the pus occur, the cerebral possible involvement must be taken 
into account. 

Confixed Suppuration. 

This is the gravest of the suppurative conditions of the frontal 
sinus. It may arise during chronic or acute suppuration, or be 
the result of an infection of a retained mucoserous secretion. It 
may appear a long while after the access of the pyogenic organ- 
isms and be the sudden development of a dormant and unsuspected 
inflammation. The sources of irritation and the causes of occlu- 



406 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

sion of the frontal canal have already received sufficient mention 
without further repetition here. 

The symptoms of the condition are such as would accompany 
the formation of an abscess in any closed cavity. There are 
usually the symptoms of the precedent condition, which, instead of 
retaining their intermittent character, gradually or it may be sud- 
denly become constant and of greater severity. Pain becomes 
constant, throbbing and boring in character, and localized in the 
frontal region. Headache is persistent and severe. The patient 
cannot sleep, and is in the severe torture of abscess-pain day and 
night. The eyes are watery and suffused. The tissues overlying 
the affected sinuses are reddened, swollen, and edematous. Pressure 




Fig. 161.— Horizontal section through the frontal sinuses, showing unilateral occlu- 
sion with consequent accumulation of secretion and perforation into the cranial cavity. 
The difference in size of the two sinuses is to be noted (after Cryer). 



becomes extremely painful. The systemic exhibition of pus- 
intoxication begins, and chilliness, sweats, and the suppurative 
fever are to be observed. With the progress of the case the reten- 
tion of pus leads to the development of pressure-effects. There is 
marked bulging over the affected area, more noticeable at the 
inner angle of the orbit. The eyeball is displaced, and diplopia 
results ; or, if the optic nerve be encroached upon in the swelling, 
amaurosis is possible. The sense of smell may be markedly 
diminished. Cerebral symptoms not unlikely ^ may supervene. 
With the continued and increasing pressure within the sinus, thin- 
ning of its walls occurs, and a distinct sense of fluctuation or of 
crackling may be elicited; and, Anally, unless relief is given by the 
surgeon, following the path of least resistance there is a rupture 
of the thinned and overdistended tissue, and the abscess forms its 
own outlet. This may take place in any direction — outward through 
the inner angle of the orbit (Figs. 161, 162), backward into the 
orbit, upward into the space between the dura mater and the inner 



EMPYEMA OF THE FRONTAL SINUS. 



407 



table of the skull, inward into the nasal cavity, or in rare cases 
outward through the external tables of the frontal bone. 




Fig. 162.— Showing the destruction to the inner wall of the orbit by the abscess originating 
in the frontal sinus. From the same skull as Fig. 161 (after Cryer). 



This last route of rupture occurred in a case of my own. The 
condition followed la grippe in January, 1898, and had persisted 
till June of the same year, when I first saw the patient. Pass- 
ing a probe oyer the tumor in the frontal area caused rupture, 
so thin had become even the covering of skin. Concluding that 
cerebral complications had ceased to be a probability, as the pus 
had followed the line of least resistance, I explored the cavity with a 
probe, which finally emerged from the normal nasal outlet. The 
cavity was thoroughly cleansed with an antiseptic solution, packed 
with gauze, gradually lessened in amount as healing progressed, 
and the patient made an uninterrupted recovery, only the smallest 
scar and indentation, about one-half inch above the supra-orbital 
ridge, showing the point of rupture. 

The relief after rupture is indescribably prompt, and with the 
free escape of the purulent material the symptoms, urgent before, 
rapidly abate. 

The diagnosis is not difficult after the establishment of the 
local swelling and the systemic symptoms. Retention of uninfected 
material lacks the acute, purulent, inflammatory symptoms to be 
observed externally. Certain tumors may grow to such extent as 
to cause the pressure-symptoms, and even, if attended by sup- 
puration, simulate the presence of pent-up pus; thinning of the 
walls may even occur, but the growth is slower and the pain less 
intense. Abscess of the lacrimal sac may confound a diagnosis, 
but the interference with the lacrimal secretion is too marked a 
feature in most cases. Transillumination is of confirmatory value. 



408 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

The prognosis should be very guarded. The swelling may 
last a long while before it is followed by rupture, or it may break 
early. It may open anywhere and become the starting point of a 
fatal meningitis. Panophthalmitis may result and require removal 
of the affected eye. Spontaneous rupture may lead to the forma- 
tion of an obstinate fistulous tract. 

That complications, more often resulting from infection of 
the frontal sinus than any of the other accessory cavities, can be 
readily understood when we consider that this sinus has a very large 
area of communication with the orbit and brain, that its walls are 
frequently very thin and often show dehiscences, the intimate re- 
lation between the veins and lymphatics of the lining membrane 
of the sinus and those of the dura mater and meninges, and 
that the cerebral wall contains numerous foramina for the trans- 
mission of small veins through which infection may travel directly 
into the cranial cavity. 

The infecting micro-organisms may invade the surrounding 
structures by one of several paths — namely, by direct continuity 
of structure, through dehiscences in the bony walls, through the 
venous anastomosis, through the foramen for the optic nerve and 
ophthalmic vein, or by way of the lymphatics. 

Periostitis and subperiosteal abscess may occur in chronic fron- 
tal sinusitis, but are more frequently seen in the acute form. 
Caries and necrosis are more often associated with the chronic 
form. These complications may involve any of the sinus walls, 
but the anterior and inferior seem to be the most frequent. As a 
result of this involvement of the bony walls, orbital complications 
occur and may take the form of a subperiosteal abscess and rup- 
ture externally, or an orbital abscess may form. 

In intracranial complications the extension may take place 
either directly, as a result of necrosis of the sinus walls, uncover- 
ing the dura and admitting the purulent material directly into the 
cranial cavity, or the septic material may be carried indirectly to 
the meninges through the intercommunicating veins. When the 
dura mater has been exposed by the destruction of the wall of 
bone against which it lies, the pus thereby comes in direct contact 
with the brain structure. The localized meningitis which follows 
results in the production of granulation tissue, which no doubt 
frequently forms an effectual barrier against further invasion of 
the pus, and thus further spread of the infection is limited. The 
dura becomes thickened over the exposed area, and adhesions take 
place between the outer surface of the dura and the edges of the 
fistulous opening in the bony wall of the sinus. On the other 
hand, this localized process may become purulent, constituting an 
extradural abscess. When the severity of the inflammatory process 
is greater than the dura can withstand, the infection passes through 
involving the pia mater, where it may become encysted, forming 



EMPYEMA OF THE FRONTAL SINUS. 409 

either an intradural or subdural abscess. If the infection does not 
become encysted, it spreads rapidly over the surface of the pia 
mater, resulting in a diffuse purulent internal pachymeningitis. 
Thrombophlebitis may result from the purulent material being 
transmitted directly to the longitudinal sinus and, in turn, this gen- 
erally ends in pyemia. 

Treatment. — The local treatment should be the same as given 
under Catarrhal Inflammation. 

Surgical procedure offers a good chance of recovery. 

The best plan of surgical interference is Bryan's operation, a 
modification of the Ogston-Luc method, which consists in the 
incision being made not in the median line,- but along the under 
margin of the supra-orbital ridge, or the radical Killian operation 
with its various modifications. When properly performed the 
Luc method leaves a very small, but not disfiguring, scar. By 
the latter or modified procedure, what slight scar is formed falls 
just under the brow, and is further concealed by the hair of the 
brow. 

After removing all obstructive tissue within the nose, such as 
polypi, exostoses, or permanent enlargement of the turbinates, the 
ethmoidal cells are examined to ascertain whether they are in a state 
of caries. If so, they are freely curetted. The eyebrow is shaved, 
and the skin of the forehead is prepared as for any surgical operation. 
The integument is pulled up on the forehead, so that the incision, 
which should commence just within the supra-orbital notch and 
be made down to the bone, falls just under the supra-orbital 
ridge. The cut is carried to the inner angle, and the flap thus 
formed, composed of the skin and periosteum, is elevated. If 
there is not sufficient room for the application of the trephine, the 
flap should be increased by carrying the incision across the root 
of the nose to the opposite inner angle. After the elevation of 
the flap, a small crown trephine about 1 cm. in diameter is placed 
about two lines outside of the median line and about the same dis- 
tance above the supra-orbital ridge. After the removal of the 
button of bone, all carious and granulation-tissue is removed, the 
frontonasal duct enlarged, and a self-retaining drainage-tube 
introduced. After thoroughly irrigating the parts with an anti- 
septic solution and touching the lining membrane of the sinus 
with a 20 per cent, solution of chlorid of zinc, the wound is then 
closed with an interrupted or a subcutaneous suture. If there 
should be any caries of the fronto-ethmoidal cells and ethmoidal 
cells proper, this diseased tissue must be removed by means of the 
curet, operating from within the sinus, and using the little finger 
within the nose as a guide. Next, a large communication is made 
between the sinus and the nasal cavity. The drainage-tube in this 
instance is done away with, and the cavity packed with iodoform 
gauze brought down into the nose. The wound is then closed 



410 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

as above described. After the removal of the gauze the cavity is 
irrigated through a curved cannula with mild antiseptic lotions 
until healing takes place. In cases in which there has been 
necrosis of the bone and much destruction of tissue the radical 
method may have to be employed and partial or complete obliter- 
ation of the sinus be necessitated. "When such radical measures are 
necessary, the methods advocated by Killian and Logan Turner, 
I think, beyond doubt, give the most satisfactory results. 

The radical or Killian operation is as follows : Prepare field of 
operation by shaving eyebrows ; scrub parts with soap and water, 




Fig. 163.— Showing skin incision in Kiliian operation on frontal sinus. 

followed by washing with sterile water, bichlorid of mercury, s-qVo"? 
and alcohol. Irrigate nasal cavity with warm normal salt solution. 
A sterile towel is placed over the head, and parts surrounded by 
sterile towels and sheets. Nasal cavity should be packed well 
posteriorly to prevent blood from entering the pharynx. 

Under ether-anesthesia a curved incision is made, dividing all 
the tissues down to, but not through, the periosteum. Beginning 
the incision at the outer third of the orbit, it is carried through 
the eyebrow, curving inward and downward to the inferior mar- 
gin of the nasal bone. Hemorrhage is controlled by the use of 
hemostats. 

The soft tissues are now dissected above and below in order to 
make the periosteal incision. The periosteal incision above is made, 
beginning at the outer extremity of the wound, parallel to, but in 



EMPYEMA OF THE FRONTAL SINUS. 411 

a plane about one-half inch above the supra-orbital ridge. The 
periosteum and soft parts are retracted above, and the sinus opened 
by chisel or gouge at a point above the supra-orbital ridge at the 
inner end of the periosteal incision. A bent probe is then intro- 
duced to ascertain the exact size of the frontal sinus. By means 
of the Killian V-shaped chisel a groove of bone is removed along 
the line which will form the superior border of the supra-orbital 
bridge, beginning at the exterior limit of the sinus and carried to 
the primary opening made into the sinus. The entire anterior wall 
of the sinus is then removed from above the bone incision by 




Fig. 164.— Showing periosteum elevated above and preliminary groove made in bone. 

means of suitable bone-forceps. The sinus mucosa is then re- 
moved with a curet. After controlling hemorrhage, the sec- 
ondary periosteal incision is made by beginning at a point under- 
neath the supra-orbital ridge and internal to the attachment of the 
pulley of the superior oblique muscle and extended down along 
the line of the primary incision. An elevator is then introduced 
and the periosteum, together with the superior oblique muscle and 
trochlear nerve, is pushed over the orbital fat, and below the lacri- 
mal duct is raised from its groove. Hemorrhage at this point may 
be quite severe, and should be controlled by packing. 

The entire inferior wall of the sinus is then removed by means 
of chisel and bone-forceps, and the opening should be extended 
toward the nasal bridge, and the frontal process of the superior 



412 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

maxillary should be removed. When the ethmoidal sinuses are dis- 
eased the entire labyrinth should be exenterated, including the re- 
moval of the middle turbinal. The anterior wall of the sphenoidal 
sinus is removed, and cavity curetted if necessary ; the posterior 
plate of the sinus shonld be carefully inspected for any areas of 
necrosis, and removed if present. See that all septal and mem- 
branous lining of the sinus is removed. 

The entire cavity should now be thoroughly irrigated with 
warm saline solution and lightly packed with iodoform gauze. The 
free end of the packing is carried down through the frontonasal 




Fig. 165.— Showing anterior wall and floor of the sinus removed. 



opening into the vestibule of the nose. The ethmoidal and sphe- 
noidal sinuses are likewise packed. The external wound is closed 
with silkworm-gut sutures. Kolled gauze compresses are placed 
above the bony bridge and internally along the eye, and over this 
several thicknesses of loose gauze are firmly held in place by a 
bandage. 

After-treatment. — The patient should lie on the healthy side 
and be forbidden to blow the nose, and should be properly in- 
structed to aspirate the secretions backward into the pharynx. The 
external dressing should be changed daily, and the packing re- 
moved on the third or fourth day. 



MUCOCELE OF THE FRONTAL SINUS. 413 



MUCOCELE OF THE FRONTAL SINUS. 

This condition arises as the result of a prolonged catarrhal 
inflammation within the sinus, whereby there is either a formation 
of myxomatous masses, a mucoid degeneration of the investing 
membrane, or proliferation of mucous cysts. Through the growth 
of these elements, there is developed a mass retained by a thin 
membrane, and consisting largely or entirely of the elements con- 
stituting normal mucus. 

The symptoms comprise exactly the same phenomena as are 
seen from the accumulation of free mucoserous fluid within the 
sinuses. They may be very obscure in the earlier stages, amounting 
perhaps to a slight annoyance over the nasal bridge or to a sense of 
weight or fulness. Usually, the symptoms of a chronic catarrhal 
inflammation have been well marked for some time, and gradually 
give way to the symptoms of internal pressure, without, however, 
the marked external phenomena, and lacking systemic purulent 
intoxication. With this exception and the less severity of pain, 
the symptoms are like those observed in the exhibition of confined 
pus. Thinning of the sinus-wall may take place and, possibly, 
escape of the sinus-contents. Degenerative changes may occur, 
and the whole mass become a homogeneous fluid, which may still 
further undergo infection, be converted into pus, and be the basis 
of a frontal empyema. Or, reaching the limits of the normal sinus, 
degenerative process may occur and the mass become softened, 
fluid escaping into the nostril through the frontal canal. 

The diagnosis is not easily made, and indeed may be impos- 
sible in some cases. The pressure-symptoms, with lack of pus- 
intoxication, together with the history of the case, furnish sus- 
picious data. It is almost impossible to separate the condition 
from that of any tumor having its site in this location. 

The prognosis is good as regards life. Empyema may result. 
The cerebral and ocular dangers are not so grave as in the filling 
of the cavity with confined pus, but are still present to a limited 
extent. 

Treatment. — Occasionally, spontaneous rupture and discharge 
may occur. However, as a rule, surgical interference is necessarv. 
In a majority of the cases this can be accomplished by perforation, 
with the instrument shown in Fig. 166, into the frontal sinus^ 
through the frontonasal duct from the nose. The danger of pene- 
trating the cranial cavity or the cribriform plate must be remem- 
bered and carefully guarded against. Yet with a thorough knowl- 
edge of the anatomy of this region to an experienced operator 
such an accident is not likely to occur. Also the absence of the 
frontal sinus must be borne in mind when attempting paracentesis. 
This operation, if successful, will permit of the exit of the retained 
material, and, should it fail to be curative, will at least be of value 



414 DISEASES OF THE ANTERIOR NASAL CAVITIES. 

from a diagnostic standpoint, besides establishing free drainage 
into the nose. The opening should be followed by curetment. 
If this method should fail to effect a permanent cure, recourse 




Fig. 166.— Palmer's frontal-sinus drill. 

will have to be made to the external operation as given under 
Empyema (page 409). 

FOREIGN BODIES. 

These may be either inanimate or animate. The former com- 
prise such bodies as spent bullets or shot, or pieces of metal, and 
the like, the existence of which within the cavity is usually known 
because of the traumatic history of the case. They may give rise 
to no symptoms, but remain firmly placed in the frontal cavity. 
On the other hand, they may constitute the exciting cause of a 
chronic catarrhal or suppurative inflammation of the sinus, which 
will refuse to yield to any treatment short of their removal. 
Fortunately, such cases are rare. 

Of the animate foreign bodies, there are a number of recorded 
cases of invasion into the frontal sinuses. These consist of a 
variety of worms or larvae and, particularly, maggots. The symp- 
toms produced are necessarily those of excruciating pain in the 
frontal sites, suppuration and fetid discharge, with ulceration and 
necrosis of the structures attacked by the insects. The diagnosis 
is made by the presence of numbers of worms in the nasal dis- 
charge and by the localizing symptoms. These cases are more 
often observed in tropical and warm climates than in the temper- 
ate zones. The prognosis must be guarded. 

Treatment. — The treatment is the same as in Suppurative 
Inflammation. However, when animate foreign bodies are present, 
relief may be obtained without resort to operative procedure by 
the application of an ethereal solution or chloroform, followed by 
flushing with an antiseptic solution, either a weak solution of car- 
bolic acid or bichlorid of mercury, 1 : 2000 or 1 : 3000. 

INFECTIOUS CONDITIONS OF THE FRONTAL SINUS. 

The frontal sinuses are liable to the invasion of erysipelas ? 
diphtheria, syphilis, tuberculosis, la grippe, etc., but such involve- 
ment is preceded by nasal manifestations of the same process, and 
is of rare primary occurrence. 



TUMORS. 415 



TUMORS. 



Various forms of benign and malignant growths may occur ; 
they may be primary, or are associated with similar tumors in 
adjacent cavities or structures. The most common are the fibroma, 
myxoma, and osteoma, given in the order of their frequency of 
occurrence. 

The fibroma is usually single, of small size, and of slow growth, 
although it may extend into the nose or, if not interfered with 
by operative procedure, extend backward and upward into the 
cranial cavity. 

The myxomata may be either single or multiple — most fre- 
quently the latter — and are of rather rapid growth. They are 
usually associated with myxomata of the nasal cavity. 

The osteomata are rather rare, and may primarily originate 
in the sinus or in adjacent bony structure, involving the sinus. 
They tend to involve adjacent structures and to penetrate the 
cranium. This tumor is of very slow growth and, if allowed to 
attain any considerable size, produces marked facial deformity. 
The malignant growths of the frontal sinus are usually secondary, 
being associated with malignant growths in adjacent structures. 
They are necessarily fatal. Cystic tumors of the frontal sinus may 
occur at any age or may be congenital. They consist in the reten- 
tion variety (mucocele), or are steatomatous in character. Tumors 
of the frontal sinus, either benign or malignant, are of grave im- 
port, and the prognosis is unfavorable. Cysts and the benign 
tumors may be removed by external incision, and, if recognized 
early, outside of some facial deformity, curative results may be 
obtained. For the malignant growths operative procedure is of 
little or no avail. 



CHAPTER XIV. 



RELATED PATHOLOGICAL CONDITIONS OF THE NOSE 
AND ACCESSORY SINUSES TO THE EYE. 

Following the diseases of the accessory sinuses and their 
relation to diseases of the nose is the consideration of the lesions 
of the lacrimal duct and the mucous membrane of the orbital cavity. 




Fig. 167.— Vertical section (after Cryer), showing a thread through the, ostium maxil- 
lare : m.s., maxillary sinus ; m.b,, malar bone ; i.o.c, infra-orbital canal ; w.n.s., wall of nose 
and sinus ; a.p., alveolar process; i.m., inferior meatus ; It, inferior turbinate; n.d., nasal 
duct; m.m., middle meatus; m.L, middle turbinate; s.m., superior meatus; f.s., frontal 
sinus. 

While this cannot be considered an accessory cavity, yet the com- 
munication established between the eye and nose by the lacrimal 
duct is more direct and more open to infection and more liable to 
extension of inflammation than any of the accessory cavities. In 
individuals in which there are extra sets of ethmoid cells and 
where the lower plate of the orbit is very thin — and this condition 
usually exists where there are extra sets of cells — an involvement 
of the ethmoid sinus is certain to produce lesions of the eye, 

416 



BELATED PATHOLOGICAL CONDITIONS OF NOSE AND EYE. 417 



particularly inflammation of the conjunctiva and the inferior con- 
junctival surface, causing excessive flow of water from the eye. 
In cases of confined suppuration or inflammatory exudate the 
pressure may cause some distention or displacement of the eyeball. 
This is especially true if associated with maxillary antrum lesions. 
Any inflammatory process spreads by continuity or contiguity 
of structure, or through the blood-vessels or lymphatics. Inflam- 
matory processes in the nose, either infectious or non-infectious, 
may extend up through the lacrimal duct by continuity of struc- 
ture, as the mucous membrane lining this duct is a continuation 
from below of the nasal mucosa, and from above is a continuation 
of the mucous membrane lining the orbital cavity. The location 
of the lacrimal duct and its environment are well shown in 
Figs. 167, 168. Inflammation, then, may spread from eye-lesions 





Fig. 168. 



Fig. 169. 



Fig. 168.— Perpendicular transverse section just within the infra-orbital ridge, anterior 
wall of the maxillary sinus removed (after Cryer). Note septa traversing the sinus; twine 
in infra-orbital canal : n.c, nasal cavity; n.s., nasal septum; i.t., inferior turbinate; i.m., 
inferior meatus; h.p., hard palate; a'.p., alveolar process; m.s., maxillary sinus; m.b., 
malar bone ; n.d., nasal duct ; f.s., frontal sinus. 

Fig. 169.— Section from posterior wall of antrum and orbit (after Cryer) ; thinned bones 
indicate old age : m.s., maxillary sinus; h.p., hard palate; i.m., inferior meatus; i.t, in- 
ferior turbinate ; n.s.. nasal septum; mi., middle turbinate; m/m., middle meatus; p.e.c, 
posterior ethmoidal cells ; u., orbit. 

through the lacrimal duct to the nose, the influence of continuity 
of structure being aided by gravity. Obstructive lesions of the 
nose, by occluding the nasal duct, may lead to accumulation of 
material within that tract, with overflow through the eye. This 
accumulation mav lead to irritation and infection, causing primary 

27 



418 RELATED PATHOLOGICAL CONDITIONS OF NOSE AND EYE. 

inflammation of the duct. While this is not a direct extension of 
inflammation from the nasal mucosa, yet the essential exciting 
etiological factor is to be found in the nasal cavity. The associ- 
ated diseases may be classified generally into : 

1. Lesions of the lacrimal duct and eye, brought about by nasal 
obstructions in the form of deflected septum, congenital or trau- 
matic, involving either the cartilaginous or bony portion, spurs or 
exostoses, tumors, enlarged turbinates, the various forms of simple 
chronic rhinitis, and foreign bodies. Simple chronic rhinitis, by 
the thickening of the membrane, but not necessarily the bone, 
oifers the same obstruction as a new growth. Operative interfer- 
ence in the nose may lead to lesions of the duct by trauma. Sep- 
tal operations in which there is introduced into the nose any form 
of tube for the support of the septum, by pressure may lead to 
obstructive lesions of the duct. 

2. Conditions in which there is no nasal obstruction, but in which 
there is an infectious inflammation of the nasal mucous membrane. 
The inflammatory process then, spreading by continuity of struct- 
ure, will extend to the mucous membrane of the eye. 

3. Inflammatory processes involving the mucous membrane of 
the eye, in which there is no lesion of the duct or nasal cavity, 
may extend from the eye to the nose. This is especially true if the 
process be infectious, although such extension will also occur in 
the non-infected varieties of inflammation. 

In membranous inflammations of the nose the process may 
extend through the lacrimal duct to the eye. I have observed 
several cases of hay fever in which there was formation of an 
actual membrane in the nose, which had extended to the eye. On 
removing the membrane from the conjunctiva, there was also 
removed an almost perfect cast from the lacrimal duct. While 
there is little danger of bacteritic infection in the healthy mucous 
membrane lining the lacrimal duct, yet from any simple inflamma- 
tory process or any condition in which there is lessened physiolog- 
ical resistance, the harmless, non-virulent bacteria find a suitable 
nidus for their proliferation, and the simple inflammatory process 
is converted into an infectious one. Even in infectious nasal con- 
ditions without an associated lesion of the lacrimal duct, the 
repeated efforts on the part of the patient to clear the nostril may 
be the means of forcing up into the duct infectious material, with 
subsequent inflammation. There is no question but that in many 
cases of simple rhinitis, either acute or chronic, the irritation 
caused by the continuous or too frequent use of the nasal douche 
may produce inflammatory processes in the accessory sinuses and 
continuous mucous-membrane structures. The important relation 
existing between the nose and eye should be carefully studied in 
the treatment of persistent inflammatory lesions existing in either 



BELATED PATHOLOGICAL CONDITIONS OF NOSE AND EYE. 419 

the nose or orbital mucous membrane, as lesions of the eye, which 
do not seem to yield to any plan of treatment, may be found to 
have in the nose the causative factor, the correction of which will 
clear up the eye-symptoms. On the other hand, a continuous 
inflammatory lesion of the nose, in which there is an infectious 
process going on in the mucous membrane of the orbit, may have 
in that its etiological exciting factor. In the anemic and stru- 
mous forms of rhinitis occurring in children, with offensive, slimy 
discharge from the nostril, with watery eyes, edematous and swol- 
len lids, with the tendency to excoriation of the skin surround- 
ing either the nasal or ocular opening of the duct, the condition 
may be an associated one — the result of a constitutional diathesis. 

The relation of disease of the accessory sinuses of 
the nose to changes in the field of vision has recently 
received considerable attention, and has been the subject of study 
by many rhinologists and ophthalmologists ; and while there have 
been many variations in their findings, they all seem to be in 
accord that the enlargement of the blind spot of Mariotte, espe- 
cially for green, is the most constant symptom present. 

The changes in the field of vision seem to be more frequent in 
the chronic forms of sinus disease, particularly those involving the 
posterior ethmoidal and sphenoidal cells. Gronholm reports a 
case of disease of the chiasm due to empyema of the posterior 
ethmoidal and sphenoidal cells. Krauss reports a case of superior 
hemianopsia, which gradually disappeared after puncture of the 
sphenoidal sinus of the same side. MacWhinnie, Coffin, J. N. 
Risley, Wallis, and others report a series of cases of sinus disease 
in which enlargement of the blind spot was found with central 
and paracentral scotomata. 

Diseases of the nasal accessory sinuses may affect the intra- 
ocular structures in a number of ways — namely, through the 
venous channels, through the arterial supply, through the sensory 
and motor nerve-supply, through the sympathetic nerves, and 
probably by general absorption of infectious material. 

The most important ocular signs and symptoms of accessory 
sinus disease are tabulated by Cunningham as follows : 

Frontal Sinusitis. — Periostitis and orbital cellulitis, exophthal- 
mos, diplopia, hyperemia of the optic disk, haziness of the vitreous. 

Maxillary Sinusitis. — Blepharospasm, lacrimation, purulent 
dacryocystitis, edema of the retrobulbar tissue, exophthalmos, hy- 
peremia of the optic disk, visual disturbance, transient amblyopia, 
amaurosis. 

Ethmoiditis. — Mucocele, purulent dacryocystitis, diplopia, ex- 
ophthalmos, amaurosis. 

Sphenoidal Sinusitis. — Paralysis of the third nerve, of the sixth 
nerve, and of the second division of the fifth nerve ; papillitis, 
retrobulbar neuritis, optic atrophy. 



420 BELATED PATHOLOGICAL CONDITIONS OF NOSE AND EYE. 

The explanation of amblyopia and amaurosis is to be sought in 
the anatomical surroundings of the optic nerve while in the optic 
foramen, where pressure may be exerted on the nerve by distention 
of the veins surrounding it, or by sympathetic edema into the nerve 
and nerve-sheath. 

Visual disturbance due to nasal disease is frequently unilateral, 
and though it is usual for the homolateral nerve to be affected, 
occasionally it is the contralateral alone. 

Chemosis, papilledema, proptosis, paralysis of the ocular mus- 
cles, and redness of the eyelids form the important ocular signs of 
that very grave disease, cavernous sinus thrombosis, often a result 
of suppuration in the sphenoidal sinus or the posterior ethmoidal 
cells. 

Occasionally disease in one of the accessory sinuses, while 
giving rise to reflex symptoms, does not exhibit any very definite 
sign of its existence, so that, attention not being directed to the 
origin of the trouble, it is at first apt to be overlooked. 

Observations have shown the group of symptoms known as 
asthenopia to be a result of disease of the ethmoid, maxillary, or 
sphenoidal sinus, and such reflex neuroses as bulbar and periorbital 
neuralgia to accompany frontal sinusitis. Blepharospasm has been 
traced to suppuration in the antrum of Highmore. 



CHAPTER XV. 
DISEASES OF THE NASOPHARYNX. 

a. Acute and Chronic Inflammatory Diseases. 

1. Acute Nasopharyngitis. 

2. Simple Chronic Nasopharyngitis. 

3. Atrophic Nasopharyngitis. 

4. Hyperplastic Nasopharyngitis. 

5. Rhinopharyngitis Mutilans. 

6. Specific Inflammations. 

(1.) Syphilis. 
(2.) Tuberculosis. 

a. Lupus. 
(3.) Glanders. 
(4. ) Actinomycosis. 
6. Neuroses. 

ACUTE NASOPHARYNGITIS. 

Definition. — An acute catarrhal inflammation of the mucous 
membrane of the nasopharynx, occurring either as the accompani- 
ment of an acute rhinitis or pharyngitis, or of both, as the acute 
exacerbation of a chronic catarrhal inflammation, or more rarely 
as a primarily localized inflammation. It is characterized by a 
protracted dry stage, followed by the abundant formation of a 
thick, tenacious, mucoid or mucopurulent discharge and a gradual 
subsidence of the symptoms. The attack runs a course of about 
two weeks, and repeated attacks tend to establish the chronic con- 
dition, if it be not already present. 

We have in the nasopharyngeal mucous membrane a condition 
which has already been described under Li them ic Rhinitis, but 
added to this should be another form of subacute inflammation 
causing a catarrhal condition, which is entirely dependent on sys- 
temic conditions, where from intestinal conditions such as chronic 
constipation, there is absorbed back into the system irritating 
material which seems to manifest itself very quickly in the pha- 
ryngeal and nasopharyngeal mucous membrane. This is probably 
due to the fact of the peculiar lymphatic and blood -supply of this 
structure. This could properly be classed under Systemic Naso- 
pharyngitis. 

The same is true of conditions involving gastric, kidney, and 
hepatic structures. 

Synonyms. — Acute catarrh of the nasopharnx ; Acute post- 
nasal catarrh ; Acute retronasal catarrh ; Acute rhinopharyngitis. 

Etiology. — Predisposing- Causes. — Chief of these may be 

421 



422 DISEASES OF THE NASOPHARYNX. 

classed the irregularities of climate, particularly those occurring 
in the spring and fall months. These become proportionately 
more active as the patient's bodily tone is below its normal. In 
many cases there is apparently an oversensitive state of the mem- 
brane of the nasopharynx, not improbably a local exhibition of a 
neurotic condition, which seems not infrequently to predispose. 
This element is more marked in the female sex. Adults seem to 
be more frequently affected than those of younger years, and the 
scrofulous diathesis strongly predisposes. A goodly proportion 
of cases are the acute exacerbations of a chronic condition. 

Exciting- Causes. — The condition may accompany an acute 
rhinitis or pharyngitis, or both, either as an extension of the inflam- 
matory process by continuity of tissue, or arising as the result of 
the same causes, acting locally, which produce these conditions. 
Such causes include the inhalation of dust, and the various chem- 
ical or mechanical irritants. Exposure to extremes of temperature, 
sudden chilling, and the like may produce it ; in short, the whole 
chain of causes which may be productive of acute rhinitis may 
exercise the same causative influence here. Certain of the infec- 
tious fevers, such as scarlet fever, measles, and diphtheria, may be 
complicated or followed by an acute postnasal catarrh. 

Pathology. — The pathology of the condition does not differ 
from that of an acute catarrhal inflammation of any mucous mem- 
brane. There are the same vascular phenomena of engorgement, 
somewhat prolonged and followed by the escape of fluid and cells 
into the submucous tissue, and an increased surface-discharge, 
both from this source and from the extra activity of the glandular 
structures, due to increased irritation. Not infrequently a few of 
the glands may be occluded at their orifices and become filled by 
cellular debris undergoing cheesy degenerative changes — a condi- 
tion characteristic of follicular pharyngitis. Finally, the stage of 
resolution supervenes, the vascular tonus is regained, the exudate 
is absorbed, and the membrane returns to the condition existing 
before the attack. Instead of resolution, evidences of a chronic 
course may appear in the attempted organization of the cellular 
elements into tissue more or less new, and the slow, impaired 
return to normal which the vessels display. 

Symptoms. — As may readily be imagined, these are of vary- 
ing degree of severity. If the nasopharyngitis is coincident with an 
acute rhinitis or pharyngitis, the symptoms of these affections may 
effectually mask the symptoms of the former. A typical well- 
marked case of acute nasopharyngitis occurring alone, however, 
usually presents the following symptoms : The onset is sudden, and, 
as a rule, is attended with mild febrile symptoms — malaise, gastro- 
intestinal derangement, a furred tongue, and a temperature rarely 
exceeding 100° or 101° F. There is an almost painful dryness in 
the postnasal space, and a sense of tightness that becomes more 



ACUTE NASOPHARYNGITIS. 423 

marked on swallowing. Pain of a neuralgic character usually ac- 
companies and is referred to the vertex, the upper pharynx, the roof 
of the mouth, and the angles of the jaws. This usually persists 
throughout the attack. Slight hemorrhages may take place. The 
dryness continues for from one to two days, and then gradually 
the secretion begins to appear, at first thick and tenacious, but 
comparatively clear, later becoming whitish and starchy, and 
finally quite purulent. This clings closely to the membrane, and 
causes continued " hawking " and spitting to remove it. Some- 
times it is forced out through the nostrils, as a rule, however, 
through the mouth ; and not a little is involuntarily swallowed and 
increases the gastric trouble, which has possibly been already 
aggravated by the establishment of the secretion. The discharge 
may irritate the nasal spaces and excite an acute rhinitis. In 
severe cases catarrhal ulcers may form. Impairment of hearing and 
alteration of the vocal tone are apt to occur, the hoarseness being 
due to interference in circulation. Cough is rarely, if ever, present. 
After lasting about ten days to two weeks the symptoms gradually 
abate, the pain lessens, the discharge decreases in amount and 
returns to normal, the congestion of the membrane disappears, and 
the attack subsides. There is rarely any tendency to involve the 
tracheal and bronchial membranes, though the lower pharynx may 
become implicated. Inspection shows during the early stage a 
reddened, swollen condition of the membrane, the surface of which 
is dry and glazed and displays many tortuous and congested ves- 
sels. Later, masses of the secretion may be seen clinging to the 
walls or hanging from them, and filling the crypts and recesses of 
the tonsil of Luschka and the fossa of Kosenmuller. 

Diagnosis. — The diagnosis is made by the history and by 
inspection of the nasopharynx. Acute follicular inflammation is 
excluded, after cleansing, by the absence of the elevations marking 
the inflamed glands. Moreover, it is accompanied by a higher 
fever at the onset. 

Prognosis. — Acute nasopharyngitis is not dangerous to life. 
It usually runs a course of about ten to fourteen days, and, if not 
already the acute exacerbation of chronic nasopharyngitis, should 
be regarded as its starting point. Early treatment may abort the 
attack or lessen its duration. 

Treatment. — The treatment of acute nasopharyngitis is 
necessarily controlled by associated and allied conditions. When 
directly associated with an acute rhinitis, the treatment employed 
is the same as given for that condition ; however, at times the 
inflammatory process is limited to the nasopharyngeal structures. 
The cause of this inflammatory condition may be either local or 
systemic. Careful attention should be given to the intestinal tract 
and any irregularities relieved. Local applications by means of 
a douche should alwavs be used as warm as can be comfortablv 



424 DISEASES OF THE NASOPHARYNX. 

borne by the patient. If there is a tendency to the accumulation of 
the secretion in the nasopharynx, relief can be obtained by washing 
out by means of the postnasal syringe (Fig. 170), using a warm 
alkaline solution, such as 8 grains of biborate or bicarbonate of 




Fig. 170.— Freeman's syringe with catheter. 

sodium to the ounce of tepid water, or an equally good cleansing 
solution is warm milk to which is added 3 to 6 grains of sodium 
chlorid. In the early stage, before secretion takes place, in 
which there are marked burning and itching in the naso- 
pharynx, due to the hyperemia and congestion, relief may be 
obtained by the inhalation of medicated vapors ; but better is the 
internal administration of a granular effervescent pilocarpin tablet 
containing y^-g- grain. This should be administered every hour 
until the secretions are established. The tablets should be placed 
in the mouth and allowed to dissolve gradually. If there is a 
tendency to a continuation of the hypersecretion and a prolongation 
of the process after thoroughly washing out the nasopharynx, which 
should be done with the alkaline solution on a cotton pledget, use 
boroglycerid, 50 per cent., with an equal amount of compound 
tincture of benzoin. If, however, a more astringent effect is 
desired, there should be used a balsam solution, such as — 

1^. Olei eucalypti, gtt. ij (.12); 

Olei cassise, gtt. ij (.12); 

Extracti pini canadensis, gtt. x (.6) ; 

Tincturse benzoini, q.s. ad fl. ^j (30.). 

If the tissue is very sensitive and markedly irritated, 3 per 
cent, cocain should be added to this solution. Quite often there is 
associated with acute nasopharyngitis a sudden blocking up of the 
Eustachian orifice and continual irritation of the orifice of the Eu- 
stachian tube. This may lead to grave complications in the ear, 
and many an attack of acute otitis media can be averted by cathe- 
terization of the Eustachian tube and drawing off the accumu- 
lated secretion. When an acute inflammatory condition of the 
nasopharynx is associated with a like condition in the anterior 
nasal cavity, the treatment is the same as that given under Acute 
Rhinitis (page 78). If the secretion is not mucopurulent, but 



ACUTE NASOPHARYNGITIS. 425 

rather thin and watery, with relaxation of the mucous membrane, 
good results can be obtained by the internal administration of — 

1^. Extracti belladonna^ gr. l (.008) ; 

Camphorse, gr. -J- (.03) ; 

Quinina3 bromidi, gr. \ (.03). 

This should be given every two hours from one to three 
days, and the physiological effect of the belladonna on the 
pharvngeal mucous membrane should be carefully noted, as this 
drug seems to have a peculiar action on the blood-vessels of the 
pharynx and nasopharynx. Systemic conditions liable to interfere 
with venous circulation should be corrected. It is well in this 
variety of nasopharyngitis, as well as in most conditions of the 
upper respiratory tract, to administer a mild purgative, followed 
by a saline. Quite often acute inflammatory conditions of 
the nasopharynx are associated with acute infectious processes. 
This part of the upper respiratory tract is often involved 
during an attack of la grippe, and frequently after the attack 
is over there is left remaining localized inflammatory areas. In 
this condition, as w r ell as in infectious processes in which the con- 
trolling inflammation is a resulting condition or is secondary, 
there is always demanded the administration of tonics, agents 
to increase vascular tone and cellular activity. There is none 
better than a capsule containing — 

1^. Pulveris kolae, gr. ij (.12); 

Ferri lactatis, gr. \ (.015) ; 

Strychnine nitratis, gr. A- to -fa (.0015-. 003). 

This should be administered after each meal. 



SIMPLE CHRONIC NASOPHARYNGITIS. 

Definition. — A simple chronic catarrhal inflammation of the 
nasopharynx. It is characterized by the constant secretion of a 
thick tenacious mucus, which may become purulent, or, in long- 
standing cases form crusts. The secretion adheres tenaciously to 
the nasopharyngeal walls, its excess gravitating slowly to the lower 
pharynx ; it is somewhat abundant, and causes constantly repeated 
efforts of the patient to remove it by "hawking." The course 
of the affection is marked by a tendency to acute attacks upon 
slight provocation, and there may or may not be an associated 
rhinitis or pharyngitis. 

Synonyms. — American catarrh ; Chronic catarrh of the naso- 
pharynx ; Chronic postnasal catarrh ; Chronic retronasal catarrh ; 
Chronic rhinopharyngitis ; Chronic adenoiditis. 



426 DISEASES OF THE NASOPHARYNX. 

Etiology. — Simple chronic nasopharyngitis is undoubtedly 
produced or favored by many causes. In a large proportion of 
cases it is the result of repeated attacks of the acute form, and 
the causative conditions of this, which are not dissimilar to those 
of rhinitis and pharyngitis, play, therefore, an important part. It 
may, however, from the prolongation of an acute attack under the 
continued influence of its exciting cause, become chronic in a 
short period, and the subsequent acute attacks be but exacerba- 
tions of the chronic condition. Not infrequently it accompanies a 
chronic pharyngitis or rhinitis, and may be an extension of either 
or both to the postnasal space. 

Predisposing- Causes. — The condition is more common in the 
young than in those of adult years. Heredity is claimed to have 
an influence in its occurrence, but this is true only in so far as 
there is an inherited peculiarity of nasal structure, or a predis- 
posing diathesis in the family history. The lymphatic and neurotic 
temperaments are regarded as predisposing, and the same is true 
of the scrofulous, anemic, gouty, and rheumatic diatheses and 
weakened personal resistance. Gastric and intestinal troubles, 
especially the prevalent " American " dyspepsia, are in some cases 
undoubtedly more than predisposing factors. A torpid liver, pos- 
sibly through sluggish performance of its function in toxic elimina- 
tion, at least favors, if not directly causes, the inflammation 
through the increased work it forces on the membrane in its 
vicarious efforts at elimination. The infectious diseases, such as 
measles, scarlet fever, etc., are often followed by the chronic con- 
dition engendered in its acute form during their course. Public 
speakers, singers, and those who suddenly are called upon for pro- 
longed and severe vocal effort, without an accompanying knowl- 
edge of proper vocal management, are apt to develop it as the result 
of repeated or prolonged irritation. Certain local conditions of the 
nasopharynx, nasal cavities, or the lower pharynx are prone to be 
attended by a chronic nasopharyngitis. Such a list would include 
especially the obstructive conditions of the anterior cavities and 
those attended with an irritating posterior discharge. The same is 
true of widely opened anterior passages, permitting a too free impact 
of unmodified or contaminated air upon the walls of the nasopharynx. 
Certain abnormalities within the nasopharynx are often attended 
by chronic inflammation. Particularly is this true of affections 
of the pharyngeal tonsil, the chronic condition often persisting 
after the atrophy of this structure. The pharyngeal bursa has been 
claimed to have an especially determinant action in the etiology of 
this lesion. The presence of inflammatory conditions, of whatever 
type, in the adjacent territory, whether in the nasal mucosa or in 
the oropharynx, are extremely liable, by continuity of structure, to 
involve the nasopharynx in a chronic catarrhal inflammation. 

Exciting' Causes. — Many of the predisposing elements already 



SIMPLE CHRONIC NASOPHARYNGITIS. 427 

mentioned may be in themselves of sufficient intensity to act as 
active causes, and, indeed, it is difficult to say in many cases whether 
certain causes are active or merely predisposing. In general, it 
may be stated that the exciting causes are of the same type as 
those producing rhinitis and pharyngitis. Prominent among them 
stands the influence of climatic conditions — a damp, variable 
climate exerting in certain cases almost a specific influence. 
Abrupt changes, chilling of the body, improper clothing, the local 
action of irritants from prolonged inhalation of smoke, fumes, or 
dust, by posterior discharges from the choanse, or in misapplied or 
erroneous pharyngeal medication by the patient or practitioner, are 
of positive causative effect. Finally, in this connection must be 
taken into account the situation of the nasopharynx, the ready 
lodgement it affords for irritant media, and the difficulty with 
which the patient can by his own efforts cleanse the region, either 
by expiratory efforts or gargles. 

From a broad general standpoint associated with clinical ob- 
servations the catarrhal conditions of the nasopharynx can be di- 
vided into two classes : first, those in which with the diseased mem- 
brane there is associated nasal obstruction, or irregularities in the 
structural formation of the nasopharynx itself, and a second, in 
which without nasal obstruction there is, however, a catarrhal 
process involving the nasopharyngeal structures. The causal 
factor in the first variety is largely mechanical, such as new 
growth within the nasal or postnasal cavity ; if one nostril is 
occluded or partially occluded there is invariably accumulation of 
secretion posterior to the obstruction, and extraneous matter in- 
haled through that nostril will lodge back of the obstruction, thus 
setting up a combined irritation by the accumulated secretion and 
extraneous material which keeps up the continual catarrhal flow. 
As a rule, when the obstruction is limited to one nostril, the other 
nostril is overworked ; in other words, there is more air passing 
through the open nostril than can be taken care of by the mucous 
membrane from its physiological standpoint. The constant stimu- 
lation of the mucous membrane of the open nostril under such 
conditions explains the frequent pathological processes observed 
under such conditions. In dealing with this variety of cases if 
the obstruction or the mechanical cause of irritation be removed 
before sufficient alteration has taken place in the mucous mem- 
brane to destroy any of its physiological functions, the prognosis 
will be most favorable. If, however, the irritating cause has ex- 
isted a sufficient length of time to bring about permanent patho- 
logical alterations of the mucous membrane, the prognosis is much 
less favorable. Inequality in the size of the nostrils is as impor- 
tant a factor as obstructed breathing. 

The other variety can be classed under what is better known 
as medical cases, the irritation of the mucous membrane being 



428 DISEASES OF THE NASOPHARYNX. 

produced by some material manufactured within the system and 
through the process of faulty elimination. Again, in all of these 
cases there must be taken into consideration the general effect pro- 
duced, not only in the mucous membrane, but in the entire 
system, by altered function in any of the excretory or secretory 
organs. In the first place, the human body in its process of metab- 
olism is nothing more than a laboratory in which is manufac- 
tured physiological materials which perform normal physiological 
functions. Any condition which will alter the chemical constitu- 
ents would necessarily alter chemical compounds produced, and in 
many instances such products act as irritants not only to the 
mucous membrane, but to the other structures in the body. The 
term uric-acid diathesis is used to cover in a general way a great 
deal. But organic chemistry will show us that uric acid is only 
one of the many forms of altered chemistry of secretions, and 
when the field of organic chemistry in medicine has been more 
thoroughly investigated we will be able to demonstrate many sub- 
stances equally as irritating as uric acid. In the majority of cases 
of this variety there is generally a history of repeated attacks of 
nasopharyngitis and the patient is very susceptible to taking cold. 
If such cases be thoroughly investigated, in every instance there 
will be found some perversion of secretion or elimination and 
some altered chemistry, due either to the fact that the secretion 
itself is not a normal physiological one and, after being secreted, 
is not properly eliminated, or else not being properly eliminated, 
is reabsorbed, giving rise to an auto-infection. Why the presence 
of this irritating material should be so frequently manifested in 
the pharyngeal and nasopharyngeal structure is hard to explain, 
but we do know that this structure is particularly susceptible to 
manufactured chemical compounds as administered in the form of 
drugs, and there is no reason why an altered secretion, or chem- 
ical compounds manufactured within the body due to altered secre- 
tion, should not show a selective action on this structure. If, 
then, the general practitioner or specialist will direct his attention 
to the correction of any irregularities within the intestinal tract he 
will find in many instances that the apparent local lesion of the 
nasopharyngeal mucous membrane will entirely disappear, and 
that instead of dealing with a local' lesion he is dealing with a local 
manifestation of a systemic condition, or, in other words, a symp- 
tom and not a disease. 

Pathology. — The general character of the morbid process does 
not differ essentially from that observed in any simple chronic inflam- 
mation, or in the beginning atrophic and the hyperplastic rhinitis. 
In its macroscopical appearance it is, as a whole, paler than normal, 
more or less boggy and edematous, and scattered somewhat pro- 
fusely over it are red punctations marking the inflammatory 
process at the glandular sites. The student should bear in mind 



SIMPLE CHRONIC NASOPHARYNGITIS. 429 

that the reddened hyperemic condition seen immediately following 
a cleansing application is not the true appearance of the abnormal 
condition. 

Symptoms. — The establishment of the condition is generally 
marked by a feeling of uneasiness, hard to describe, in the upper 
part of the pharynx. The patient usually complains of an unnatural 
dryness, with a sensation as of a foreign body lodged within the 
postnasal space. He " hems " and " hawks," and may even retch 
and vomit in his efforts at dislodgement — possibly expectorating, 
as a temporary relief, a certain amount of tenacious secretion of a 
character varying with the progress of the disease. This feeling, 
with the accompanying efforts at dislodgement, is usually worse 
in the morning, and the expectoration is then proportionately 
greater in amount. In mild cases the relief obtained through 
these eiforts may be more than of merely temporary duration, and 
the patient is compelled to repeat it but a few times daily. In 
severe cases the secretion may be so great as to necessitate almost 
continually a clearing of the throat to obtain relief from the annoy- 
ing " dropping/' as the patient usually expresses it, which may 
become still more aggravating from spasmodic cough caused by the 
irritation of the lower pharynx. The character of this discharge 
varies with the chronicity of the case. Early in its establishment 
it is thick, tenacious, clear and whitish or gelatinous in character. 
Later it becomes mucopurulent or purulent, and varies in color 
from a light yellow to a dirty shade of green. Still later it may 
show a decided tendency to the formation of scabs and crusts, or 
take the form of thick, semi-solid lumps. Saprophytic infection 
may take place, with the development of a disagreeable odor, pos- 
sibly intensified by the fetid breath of a disordered stomach. Not 
infrequently the expectoration is slightly blood-streaked. The 
connected aural structures rarely escape implication. The hearing 
is impaired, and tinnitus aurium is often associated — both possibly 
dependent upon improper balance of the intratympanic pressure. 
The voice is weakened and becomes muffled and thick, clearing 
after expectoration. Varying with the severity of the case, and 
with individual cases, certain other symptoms occur. Thus, dull 
frontal or occipital headache, pain in the nape of the neck, a dull, 
heavy, tired feeling in the head, with annoying incapacity for work, 
either manual or mental, and possibly transient loss of memory 
may occur. Digestive disorders, exhibiting their presence in a 
fetid breath, coated tongue, fever, constipation, and a general 
atonic state of the bodily structures, are of frequent occurrence. 
To the symptoms referable to the nasopharynx may be added 
those of an accompanying chronic rhinitis, pharyngitis, or laryn- 
gitis, with a proportionate intensification of the symptoms of 
the disease proper. The duration of the process is marked 
by frequent exacerbations, in no wise different from acute 



430 DISEASES OF THE NASOPHARYNX. 

attacks. Inspection of the postnasal space before cleansing 
shows the contour of the cavity to be swollen, the orifices of the 
Eustachian tubes occluded, and the surface covered with the 
characteristic secretion, either in a roughly uniform coat or in dis- 
crete masses closely attached or slowly descending the pharyngeal 
wall. Especially is this marked over the pharyngeal tonsil, and 
ofttimes the pharyngeal bursa may be located by the somewhat 
triangular mass of secretion pointing to it. In long protracted 
cases swelling and relaxation of the soft palate and uvula may also 
be noted as concomitant occurrences, while evidences of an accom- 
panying pharyngitis or rhinitis may be observed. 

Diagnosis. — The diagnosis of simple chronic nasopharyngitis 
is usually not difficult. The story of the patient, his efforts at 
expectoration, the chronicity and personal history of the case 
furnish ground for a diagnosis, which the rhinoscopic examination 
of the postnasal space readily confirms, or as readily disproves. 

Prognosis. — The disease is not dangerous to life, and may 
disappear as middle age is reached ; on the other hand, it may lead 
to atrophic changes in the nasopharynx. The outlook as regards 
extension to or involvement of the connected structures, especially 
the ear, does not admit a positive prognosis either one way or the 
other. 

Complications. — A simple chronic inflammatory process 
may predispose the tissues and render the individual more suscep- 
tible, especially in early life, to the infectious diseases, particularly 
the eruptive fevers. There is frequently associated gastric dis- 
turbance, due to the individual unconsciously swallowing the 
accumulated secretion, especially during sleep and on eating. 
Besides, the accumulated material, by its irritation not only of the 
nasopharynx, but the structures below, predisposes the pharyngeal 
and laryngeal structure to inflammatory processes, and not only 
laryngeal, but again, in turn, bronchial irritation and catarrhal 
affections of the air-vesicles. By the swollen and thickened 
mucous membrane the Eustachian orifice may be closed, and 
serious lesions of the ear result. 

Treatment. — The application of non-irritating solutions is 
essential. At the same time, the long-continued and repeated use 
of such solutions may only aggravate the condition and bring on 
acute attacks. If the structure is markedly thickened and obstruc- 
tive in character, surgical measures should be promptly adopted. 
Local applications of astringents in the form of sprays or by means 
of the curved applicator and cotton pledget are highly beneficial. 
A slightly astringent antiseptic solution which will give good 
results is 1 drop of carbolic acid, 5 grains of biborate of soda, 
12 drops of glycerin to 1 ounce of water. The application by 
means of the cotton carrier of a 1 : 2000 trichloracetic-acid solu- 
tion, or a 2 to 5 per cent, solution of chlorid of zinc, or 8 grains to 



ATROPHIC NASOPHARYNGITIS. 431 

the ounce of sulphocarbolate of zinc, or compound tincture of 
benzoin with equal parts of 50 per cent, boroglycerid, is equally 
beneficial in selected cases. The selection of the astringent, as 
well as its strength, is determined by the severity and gravity of 
the case. 

In making the application to the postnasal space care should 
be taken to have the probe so curved that the posterior part of the 
soft palate can be thoroughly mopped, as this is the common site 
for the lodgement of secretion. Unless this precaution is taken 
the solution will reach only the postpharyngeal wall. 

CHRONIC EPIPHARYNGEAL PERIADENITIS IN ADULTS. 

A condition described by James E. Logan as chronic epi- 
pharyngeal periadenitis is of such importance, not only because of 
the nasopharyngeal lesion, but on account of the involvement of 
the Eustachian tube, and secondarily the ear, that I take the liberty 
of quoting the article, which is as follows : 

"As its name implies, this is a disease of the tissues in the 
vault of the pharynx. The writer is not content with the term 
1 periadenitis ' — as interpreted literally it would indicate that the 
structures surrounding the glands are alone involved, while it is 
intended to comprehend a pathologic process extending through- 
out the glandular, muscular, vascular, and connective tissues. 

" In 1903 I read before the American Laryngological Associa- 
tion a paper entitled ' Adenoid Growths with Special Reference to 
Adult Condition/ in which I recited my experience in operating 
upon 65 cases of adults over twenty-five years of age. I shall 
attempt to give further proof of the importance of recognizing 
this as a distinct disease, deserving a separate classification along 
with other inflammatory processes of the upper respiratory tract. 
Writers upon this subject have generally considered this condition 
as an extension of inflammatory processes either from the nose or 
from the pharynx into the epipharynx, making this a secondary 
and not a primary affection. In the light of our experience, we 
are convinced that in these structures are developed the etiology 
and pathology of many diseases which have baffled the efforts of 
our greatest men in the sphere of investigative research. We have 
been taught to believe that after the age of puberty has passed the 
lymphatic glands undergo atrophy and ultimately disappear, and 
clinical facts bear out the fact of this statement within certain 
limitations. Whenever the age of childhood has passed without 
establishing pathologic processes of a chronic nature within these 
structures, then atrophic changes take place that very soon obliterate 
their existence. But whenever chronic inflammations once become 
installed they seldom, if ever, disappear. In entering upon the 
discussion of the pathology of this disease w T e shall not attempt to 



432 DISEASES OF THE NASOPHARYNX. 

go into the details of the acute forms of this affection, leaving that 
to some future time. 

"In 1868 Luschka described indefinitely a chronic disease of 
the nasopharyngeal bursa, to which he gave the name ' chronic 
nasopharyngeal bursitis/ Later, in 1885, Thornwaldt gave a 
more detailed account of this affection, to which our text-books 
have ascribed the name l Thorn waldt's disease.' 

" Ballenger mentions it as a disease of the recessus medius, due 
to inflammatory adhesions of the median borders of the adenoid 
mass. Schwabach regarded it as a disease of congenital origin, 
situated in the remnant of the middle cleft. 

" In determining the actual pathology of this disease I have 
submitted a number of these growths to Dr. Frank J. Hall, of 
Kansas City, who has spent much time investigating the charac- 
teristics, and I am indebted to him for valuable aid. I give his 
report at length : e The tissue removed from the epipharyngeal 
region of Mr. D. by you and sent to me for microscopic examina- 
tion and description presents the following : The gross specimen is 
roughly circular, one inch in diameter and three-eighths of an inch 
thick. Sections made at right angles to the surface present the 
following : The covering is squamous epithelium, which is broken 
at one point by an ulcer, whose floor is composed of polymorpho- 
nuclear leucocytes held in a reticulum of fibrin. At one other 
point the surface epithelium is being invaded by leucocytes and 
round cells. This area lies directly over a lymphoid deposit re- 
sembling tonsillar tissue. Beneath the epithelium at all points the 
submucosa is liberally infiltrated with round and polymorphonuclear 
cell exudate. Here and there is a deposit of lymphoid tissue whose 
lymph sinuses are choked with inflammatory products. Deeper 
down groups of mucous glands are encountered. The lumina of 
these glands are wide and filled with a liberal amount of secretion. 
About the glands just mentioned are liberal deposits of inflam- 
matory round cells of the plasma of the small leucocyte type. In 
the planes of connective tissue at the level of the mucous glands 
is a noticeable amount of fibrin, almost sufficient to constitute a 
severance of the overlying submucosa from the gland-bearing area. 
Still deeper, planes of voluntary muscles are encountered. Between 
the individual fibers of the muscles is a great quantity of inflam- 
matory material, both cellular and fibrinous, constituting a real 
interstitial myostitis. Throughout all the section, and particularly 
marked in the upper layer of the submucosa, are many degenerated 
nuclei of the proper connective tissue. These degenerated nuclei 
are drawn out in the most bizarre fashion into clubs, strings, etc. 
No giant-cells or other specific histologic cell elements or arrange- 
ment of same is noticeable. Blood-vessels are all the seat of 
thickening of the intima and media/ 

" You will observe from Professor HalFs report that this disease 



CHRONIC EPIPHARYNGEAL PERIADENITIS IN ADULTS. 433 

does not alone involve the glandular structure, but extends to the 
muscular, vascular, and connective tissues as well. "We believe 
this to be of especial importance with reference to the muscles con- 
cerned in the function of hearing. The tensor tympani, tensor 
palati, and the levator palati are to be mostly considered in this 
connection because of their attachments into and around the orifice 
of the tube, influencing, as they do, the action of the drum mem- 
brane, together with the effect upon the lumen of the tube, by the 
opening and closing functions of the levator and tensor palati. 
These muscles originate in and around the orifice, and any inflam- 
matory process in adjacent tissue undoubtedly involves these fibers 
and must of necessity interfere with their physiologic action. This 
might serve to explain the yet unsettled theories of sclerosis of the 
middle ear. Chronic catarrhal inflammation of the middle ear has 
been the bugbear of every pathologist. He has never been able 
to establish its identity. We know that these cases progressively 
increase in deafness, even when they are given the very best atten- 
tion. In the light of these facts, it is already evident that either 
these conditions are irremediable or the etiology, pathology, and 
its elimination are yet unknown. Buck, in his third revised edi- 
tion, p. 41, says : ' As yet we are unable to form any very accurate 
idea of the extent to which the impaired hearing in this class of 
cases (referring to chronic catarrhal deafness) is to be attributed to 
abrogation of the functions of the tensor tympani and stapedius 
muscles. The sclerosing process undoubtedly invades both of 
them, and to a greater or less extent paralyzes their action ; and it 
is also conceivable that in certain cases a state of permanent con- 
tracture may be produced whereby the membrana tympani, on the 
one hand, and the stapedic vestibular-annular ligament, on the other, 
are kept by these muscles permanently in an abnormal state of 
tension/ 

"Retraction of the membrana tympani is more often dependent 
upon the lack of resiliency of the tensor tympani than upon any 
perceptible encroachment upon the lumen of the tube. This fact 
can be proved in a large proportion of cases by catheterization. 
It can also be proved by the unimpeded introduction of the bougie 
through the tube. If the tube permits of the entrance of air and 
also of the introduction of the bougie, then why does the mem- 
brana tympani remain retracted? The answer to this question 
seems to me to be found in the foregoing statement, viz., the lack 
of the resiliency of the tensor tympani. Admitting that sclerosis 
(a process hard to define) does become established within the drum, 
then it must have a cause, and that cause in a great majority of 
cases is to be found in a diseased condition of the epipharynx. 
This disease may exist indefinitely without producing any disturb- 
ance in the function of the ear, though this is the most frequent 
complication. 

28 



434 DISEASES OF THE NASOPHARYNX. 

" Whenever the tissues in the vault have been the seat of re- 
peated attacks of acute inflammation, supervening upon the chronic 
process, we have found these patients frequent victims of acute 
rhinitis and of epidemic influenza. The reason for this lies in the 
productiveness of this soil for the cultivation of all forms of 
pathogenic bacteria. In 42 cases of acute epidemic influenza in 
adults, in which were found the catarrhalis, every one exhibited a 
greater or less amount of lymphoid and connective-tissue hyper- 
trophy in the vault. I desire to lay special stress upon the ques- 
tion of the amount of this hypertrophied tissue. In my experience 
the smallest amount of it is sufficient to furnish a field for the cul- 
tivation of infectious material. 

" We must realize that in adults the process of deterioration of 
this lymphoid structure can leave but a little of the growth in all 
but exceptional cases ; but the point we wish to bring out is that 
even the slightest amount may be the origin of widespread invasion. 
In 2 of my cases there existed the smallest possible amount of 
hypertrophied tissue, yet the removal of it brought about good 
results. In 2 other cases the presence of this periadenitis was the 
determining pathologic process of the chronic suppurative otitis 
media. A fourth case was of especial interest, showing the effect 
of bacterial invasion into the right ear during measles in child- 
hood, and the development of a chronic progressive deafness in 
the left ear at the age of twenty-eight. 

" Diagnosis of this disease is a matter of little difficulty. In 
the routine of all nasal, aural, and pharyngeal examinations we 
carefully inspect the vault in every instance. With the rhino- 
scopic mirror we can in most cases determine fairly well the con- 
dition of the epipharynx ; but we should always go farther and 
introduce the finger behind the soft palate. By this means every 
evidence of adventitious tissue in this space cannot fail to be dis- 
covered. This upholstered mass may exist in considerable thick- 
ness without destroying the symmetry of the cavity. 

" The obtuseness of the angle made at the juncture of the basillar 
process with the spinal column varies greatly in different skulls, 
consequently the mirror alone may lead to mistaken idea of the 
amount, while the keen sensibility of a clean finger is a never- 
failing indicator. 

" The prognosis in these cases is usually favorable, so far as 
the vault condition is concerned. As to the disappearance of com- 
plications, this depends upon what organs and functions are in- 
volved, the age of the patient, and the amount and character of 
the impairment. Within the last six years I have operated upon 
652 cases of adenoids, both young and old, in my private practice. 
Of this number, 368 were below the age of twenty-five years and 
284 were from twenty-five to fifty-nine years. Of the 284 adults, 
162 were males and 122 were females; 167 between the ages of 






CHRONIC EPIPHARYNGEAL PERIADENITIS IN ADULTS. 435 

twenty-five and thirty-five, 106 between thirty-five and forty-five, 
and 11 between the ages of forty-five and fifty-nine. I have seen 
1 case sixty-fonr years of age, with large epipharyngeal growth, 
but was not allowed to operate. Of the 281 adults, 210 suffered 
from chronic progressive deafness in varying degrees of severity, 
24 were victims of recurrent attacks of acute and subacute catar- 
rhal otitis media, 17 had chronic suppurative otitis, and 33 
exhibited no ear complications of any moment. Of the 210 
cases of progressive deafness, 182 showed noticeable improve- 
ment after operation. This number represents those who faith- 
fully persisted in the after-treatment, and whose conditions were 
not so disastrous as to preclude the possibility of some benefit. 
Twenty cases were of such long standing and of such a character 
that the after-treatment failed to bring about any appreciable im- 
provement. These patients gave marked evidence of internal ear 
complications ; the remaining 8 cases were operated upon and little 
or no after-treatment was given. 

" Of the 24 cases of recurrent acute and subacute otitis oper- 
ated upon, 16 have had no recurrence of the discharge, and the 
hearing has been improved ; 5 have had recurrent attacks — in 3 
of these I have recently done the preliminary stripping and sec- 
ondary removal, as in the first operation I failed to get rid of the 
hypertrophies about the orifice of the tubes ; 3 cases were operated 
upon and I have lost sight of them. 

" Of the 17 cases of chronic suppuration of the middle ear 
occurring in adults over twenty-five years of age, 5 have had no 
recurrence after the removal of the growth in the vault, 8 required 
subsequent curettage of the necrosed tissue of the middle ear, and 
4 demanded the radical operation. Of the 33 cases operated upon 
showing no ear complications, all of them exhibited symptoms of 
nasal and epipharyngeal diseases of various kinds. Four were in- 
patients who had recurrent hemorrhagic expectoration without 
evidences of lung complication, and so far have had no return of 
the trouble. Five cases had active suppurative inflammation in the 
epipharynx accompanying atrophic rhinitis. Twenty-four were 
cases of various nasal and pharyngeal conditions where the peri- 
adenitis seemed to be the predominant etiologic factor. In more 
than 75 per cent, of these cases turbinarhypertrophies were present. 
Deflections of the septum existed in the usual proportion. Sinus 
complications were present in 22 — a little less than 10 per cent. 

" In summing up the question of prognosis, my experience leads 
me to say that whenever a case presents itself exhibiting any dis- 
ease whatsoever of the nasal or accessory sinuses, the middle ear, 
the pharynx or larynx, and at the same time there is evidence of 
the smallest amount of adventitious tissue in the epipharynx, the 
promp removal of this mass adds greatly to the chances of per- 
manent relief. If I may be pardoned for appearing extreme and 



436 DISEASES OF THE NASOPHARYNX. 

overzealous, I will go still farther and say that permanent good is 
practically impossible if this fertile field of infection is not de- 
stroyed. 

" It is hardly necessary to dwell at length upon the Symptoms 
of this disease, as to go into detail would involve the question of 
complications which are so varied that your patience would cease 
to be a virtue. Just a few points I desire to bring to your atten- 
tion : First, the general symptoms are those complained of by 
patients suffering from the ordinary phases of nasal inflammations, 
viz., repeated attacks of acute coryza, especially of the infectious 
influenza type ; sensations of fulness in the vault and pharynx and 
a more or less desire to hawk and expectorate, especially upon 
arising. Each morning the patient may remove a large mass of 
inspissated mucopus; during the day a large amount of mucus and 
mucopus is secreted. 

" As heretofore stated, a very large majority of my cases were 
coexistent with hypertrophies of the nasal mucosa, and in many 
deflections of the septum were present. Consequent symptoms of 
these conditions were present. The same may be said of those 
showing sinus complications. Secondly, the invaluable aid given 
us by the mirror, enabling us to see the actual conditions, and, 
lastly — and by all means the most important information revealed 
by the introduction of the thoroughly sterile finger behind the 
soft palate — all conspire to render plain the symptoms of this 
disease. 

" The treatment of this condition can be nothing less than a 
total extirpation of the diseased tissue. If allowed to remain it 
will suffer repeated invasions of acute inflammations, and render 
ultimate relief, even to the remotest complication, impossible. 

" Situated as it is, high up in the vault and in the fossae on 
either side, it has been almost impossible to devise an instrument 
that will serve the purpose of total extirpation. Failing in so 
many instances to remove the tissue in the fossae and about the 
orifices of the tubes, I have resorted to the following method : 

" Thoroughly cleanse the epipharynx and the nose with a warm 
sterile normal salt solution by means of the postnasal syringe. 
Through the nose, by means of long, curved applicators wrapped 
with cotton, apply an 8 or 10 per cent, solution of cocain several 
times for ten or fifteen minutes. In the intervals of this applica- 
tion I also apply a solution of suprarenal extract about twice 
through each nostril. Within this time the vault is well anesthe- 
tized. "With thoroughly sterile hands the right index-finger with 
long, sharp nail is introduced behind the palate. Beginning at the 
lower border of the left Eustachian orifice, proceed to break up all 
the adhesions and upholstered mass within the vault. In other 
words, strip the growth away from its bed wherever it can be felt. 
The result of this preliminary operation is to free the tubes and 



ATROBHIC NASOPHARYNGITIS. 437 

the fossae of the resisting mass, which is almost impossible to re- 
move by forceps or curet. An active inflammation follows this 
procedure, which renders the tissue brittle and susceptible of easy 
separation from the underlying structures. After an interval of 
forty-eight hours the secondary operation is performed. This is 
done by the use of the curet in a large proportion of cases. In 
well-trained throats the Brandagee forceps may serve good purpose. 
In the selection of the curet I prefer the Beckmann pattern. 
After the operation the finger should be introduced behind the 
palate to make sure that none of the growth remains. The size 
of the curet depends upon the width of the space between the 
tubal orifices — the No. 4 Beckmann is the size I usually employ. 
Another important point is that the curet should be pushed high 
into the vault, following closely the posterior border of the septum, 
so as to engage the mass. Then, changing the grasp of the instru- 
ment so that the dorsum of the hand is upward, firmly and quickly 
with a wrist movement cut backward and downward, following 
the under surface of the basillar and the anterior surface of the 
spinal column. This procedure, if done with a sharp instrument, 
will deliver the growth into the mouth — sometimes out into the 
lap of the patient or upon the gown of the operator. I have per- 
formed this operation in this manner two hundred times and have 
not had occasion to use a general anesthetic. In fact, I would 
hesitate a long time before giving ether or chloroform to an adult, 
first, because the operator is at a great disadvantage by reason of 
the lying-down position of the patient, and, secondly, there is much 
greater danger of hemorrhage. 

" The advantages of the primary and secondary operations are : 
First, the operator can break up all adhesions easily and strip the 
mass from its bed in the fossae of Rosen muller, where it exists in 
greatest abundance ; second, this mass cannot be removed in its 
entirety in these fossae without the greatest difficulty by the use of 
forceps or curet ; third, the finger will detect hypertrophies where 
the mirror will fail to reveal them ; fourth, the danger of severe 
hemorrhage is practically eliminated by the preliminary stripping 
of the mass. This procedure breaks up the continuity of the 
blood-vessels, which undergo degeneration within forty-eight hours, 
at which time the growth is removed. In all of my experience 
with this method so far I have had but 3 cases of hemorrhage 
which required plugging." 

ATROPHIC NASOPHARYNGITIS. 

The atrophic lesion occurring in the nasopharynx is usually 
associated with the same condition in the anterior nasal cavities, 
although it is possible for it to occur independently. It is well 
known that the inflammatory conditions of the mucous membranes 



438 DISEASES OF THE NASOPHARYNX. 

do not always extend by continuity of structure, but that the 
process occurring in the various mucous membrane structures is 
brought about by the same etiological factor. 

The atrophic process in the nasopharynx is identical with that 
in the anterior nares ; however, the conformation of the nasophar- 
yngeal space may have something to do with the aggravation of 
the condition. 

Frequently the individual has a very narrow nasopharyngeal 
space, and the posterior wall, not continuing down into the 
pharynx, has a slight curvature just at the point where the soft 
palate closes back against the nasopharyngeal wall. In such 
cases the attachment of the faucial arch to the lateral pharyn- 
geal wall will, with the nasopharynx, make a pocket on each 
side. While in atrophic rhinitis there is always a tendency to 
collection of secretions, owing to their altered character and 
tenaciousness, yet with this pocket-formation there is an in- 
creased tendency to accumulation just at that point. It is in 
such cases that the patient complains of the sensation of a 
foreign body in the pharynx, and where there is a constant 
hawking, with repeated efforts to clear the throat. The same 
condition, as far as accumulation of secretion and alteration 
of the mucous membrane go, may also exist in the oropharynx. 
The accumulation within the nasopharynx will not only take place 
on the postpharyngeal wall and in the pockets formed by the 
soft pillars in the lateral walls, but also on the posterior portion 
of the anterior postnasal wall. In freeing the postnasal space 
from these pent-up secretions this is often overlooked, and the 
tenacious material is left clinging to the posterior w r all of the soft 
palate. 

The most serious complication of the atrophic form of naso- 
pharyngitis is the involvement of the Eustachian tube. Owing to 
the accumulation of the altered secretion, there is a suitable nidus 
formed for the invasion of infectious bacteria. Not only may the 
infectious process extend up in the Eustachian tube, but the venti- 
lation of the middle ear is markedly interfered with by the accu- 
mulation of this material about the orifice. The occurrence of the 
atrophic form occurring within the nasopharynx as a separate 
condition does not exist. While it may exist as such in the 
pharynx, yet its pure limitation to the nasopharynx has not been 
described. 

In some forms of the simple chronic rhinitis there is a marked 
tendency for the secretion to lodge in the nasopharynx, with crust- 
formation, but the atrophic process has not taken place in the 
mucous membrane lining that structure. The pathology of the 
changes which occur in the various forms of the atrophic process 
involving the mucous membranes has been thoroughly considered 



ATROPHIC NASOPHARYNGITIS. 439 

under the heading of Atrophic Rhinitis (page 125). The diagno- 
sis can be easily made by the associated conditions. The prog- 
nosis is governed by the same rules given under Atrophic Rhinitis 
occurring in the Anterior Nasal Chambers. 

Treatment. — In treating this condition, the same general 
local and systemic treatment should be employed as given in the 
chapter on Atrophic Rhinitis. However, much difficulty may be met 
with in endeavoring to free the anterior wall of the nasopharynx of 
the secretion. This can be done by the postnasal syringe (Fig. 170), 
in which a tepid alkaline antiseptic solution should be used freely. 
This should be followed by hydrogen peroxid (15 volume). Even 
with the free use of these solutions, some of the material may still 
cling to the nasopharyngeal structure. If, then, the curved appli- 
cator is used, on which a pledget of cotton is carefully wrapped, 
the surface may be freely mopped and many of these tenacious 
crusts loosened. 

In the very early stage, where the membrane presents a shiny, 
glistening appearance, looking as if it is coated over with a thin 
layer of varnish, the prognosis is much more favorable, because 
at this stage there is only incipient change in the muciparous 
glands, with no marked alteration in the nasal mucosa. There 
should be administered at this stage tonic alteratives, one of the 
best being the compound wine of iodin (Llewellyn's) : 

^. Phosphori, gr. ^ (0.0006) ; 

Iodini, gr. i~±- (0.008-0.01) ; 

Bromini, gr. l-±- (0.008-0.01) ; 

Vini Xerici, 3j (4.0). — M. 

all the ingredients of which are eliminated by the mucous mem- 
brane. At the same time, attention should be given to the correc- 
tion of any perverted gland-secretion by the administration of 
drugs having this constitutional effect. As the disease advances 
and the accumulations become more marked, forming " slugs " 
which are distinctly offensive, the possibility of cure becomes 
more remote. 

There is a variety of atrophic conditions of the nasopharynx, 
which I believe to be due largely to lesions of the stomach or 
various gastric disturbances. Much can be done for the relief of 
this form of nasopharyngitis by the early recognition of the causa- 
tive factor ; yet in many cases, before any atrophic process or dis- 
eased process of the nasopharynx is brought about, the remote 
lesion causing such condition has progressed to a chronic form, 
rendering cure less likely. 

The peculiar dry, cracking sensation experienced by the patient 
is most disagreeable. The accumulated secretion, by its irritation 
and by the violent efforts on the part of the individual to effect 



440 DISEASES OF THE NASOPHARYNX. 

its dislodgement, frequently causes gagging and, indeed, vomiting. 
For this disagreeable dryness affecting the nasopharynx and 
pharynx, sprays of the essential oils will give the best results. 
The oil of cassia and the oil of sandal-wood, of each 6 drops to 
the ounce of liquid albolene or benzoinol, used either as a spray 
or dropped into the nostril by means of an ordinary medicine- 
dropper and allowed to filter through into the posterior naso- 
pharynx, is one of the best remedial agents. This should be 
repeated every two to four hours, or as often as the symptoms 
demand. Equally beneficial results may be obtained by mopping 
or spraying the surface with petroleum. Besides the relief given 
by overcoming the dryness, the essential oils are also beneficial in 
stimulating the muciparous glands or follicles. If \ drop or 1 
drop of the essential oil of mustard be added to the above solution, 
this stimulation will be markedly increased. 

HYPERPLASTIC NASOPHARYNGITIS. 

The etiology of hyperplastic nasopharyngitis is the same as 
that occurring in the anterior chambers, and the variety is limited 
to such conditions, in which there is an overgrowth of the con- 
nective tissue of the submucosa, which is not followed by con- 
traction and is identical with the same process occurring in other 
structures, as in the so-called hypertrophic variety of cirrhosis of 
the liver. The tissue usually involved in the nasopharynx is the 
posterior and inferior ends of the turbinated bodies, especially the 
middle and inferior. This may be associated with the same lesion of 
the anterior nasal cavity, or it may be a separate and distinct process. 
As far as macroscopical appearance of the tissue goes, there is very 
little difference observed on rhinoscopic examination between 
the hyperplastic and the simple chronic rhinitis. However, 
the hyperplastic variety, while it may be lobulated, usually 
has a smooth surface, and the superficial growth usually 
resembles that of a benign tumor, and in appearance is almost 
identical with that of the adjacent structure. The masses may 
be so large, especially when the middle and inferior turbinates are 
involved, as to occlude the Eustachian orifice. However, in the 
hyperplastic variety, lesions of the Eustachian tube are not as 
frequent as in the atrophic. The symptoms are those of post- 
nasal obstruction, and have been given in the previous chapters, 
so they do not need repetition here. 

As to treatment, there is only one thing to do — remove the 
excess of tissue. As it is a pure overgrowth or hyperplasia, it is 
not influenced by local applications or internal medication any 
more than a benign tumor would be by such treatment. Operative 
interference may be made either through the anterior nasal cham- 



RHINOPHARYNGITIS MUTILANS. 



441 



bers or through the mouth, and can be accomplished either with 
the curved postnasal snare (Fig. 83) or the biting-forceps (Fig. 
171). The after-treatment usually consists merely in thorough 




Fig. 171.— Cohen's postnasal biting-forceps. 



cleansing of the parts with antiseptic, alkaline solutions. Should 
hemorrhage occur, the surface should be mopped with a 6 to 10 per 
cent, alumnol solution ; if the hemorrhage is severe, plugging of 
the nasopharynx may be necessary. 



RHINOPHARYNGITIS MUTILANS. 

Definition. — An ulcerative process involving the nasopharyn- 
geal structures with marked and peculiar destruction of tissue. 
The disease is limited to certain areas of the tropics. There are 
no constitutional symptoms, the ulceration seems to be self-lim- 
ited, and there is a marked tendency to scar-tissue formation. 

Etiology. — Xo definite etiological factor has been deter- 
mined, but it is supposed to be of bacterial origin. 

Pathology. — The pathology of this disease, as far as the de- 
struction of tissue is concerned, differs very little from any other 
ulceration, except that it is not accompanied by any marked con- 
stitutional phenomena or very marked local symptoms. The 
ulceration is peculiarly destructive and self-limited. 

Symptoms. — Early in the disease the patient complains of 
sore throat. The ulcer appears in the pharynx, posterior faucial 
pillars, posterior border of the nasopharyngeal surface, and free 
edge of the soft palate. It starts as a superficial ulcer and is 
covered with a brownish secretion or slough. The tissue grad- 
ually breaks down and ulcer forms and spreads, involving the 
entire nasopharynx, soft palate, and, unless arrested spontane- 
ously or by treatment, frequently involves the hard palate and 
the bony and soft structures of the nose, causing frightful disfig- 
urement. The disease rarely, if ever, extends below the pharynx, 



442 DISEASES OF THE NASOPHARYNX. 

but seems to be limited to the lymphatic area of the upper 
respiratory tract. 

Diagnosis. — Few cases are seen in this country, and, if so, 
are contracted in the tropics. It would not be confused with lep- 
rosy on account of the tendency to spontaneous cure and the 
absence of lesions of leprosy ulcer ; also the absence of the bacil- 
lus leprae. Microscopic examination would easily differentiate 
this lesion and leprosy. 

Prognosis. — If the disease occurs in early life it is more 
serious and likely to prove fatal. In adult life, however, the dis- 
ease is not so serious, so far as life is concerned, but the de- 
struction of tissue and disfigurement are very marked. 

Treatment. — So far no definite line of treatment has been 
outlined to successfully combat this disease. However, those 
who have had experience in the tropics recommend cauterization 
with the silver nitrate stick, keeping the parts thoroughly cleansed 
by means of antiseptic sprays and douches. Internally, the best 
results have been obtained by the administration of alteratives, 
especially the iodic! of potassium. Careful attention should be 
given to hygiene and outdoor exercise. The patient should be well 
nourished. 



SPECIFIC INFLAMMATIONS. 

The specific inflammations are included with those of the 
uvula, tonsils, and pharynx. 

NEUROSES OF THE NASOPHARYNX. 

The various reflex troubles associated with or dependent upon 
alterations in the structure of the nasopharynx have not been so 
carefully studied as those of other portions of the upper respiratory 
tract. There are^ however, quite a number directly traceable to 
lesions of the nasopharynx. The most common which have been 
noted are attacks of laryngismus stridulus, general convulsive 
seizures, and stammering. Certain forms of gastro-intestinal 
trouble, like vomiting and eructation, may be reflex, but are more 
likely to be due to the irritation produced by the swallowing of 
the secretion from the nasopharynx. The aural reflexes are more 
a complication or result due to the inflammatory process extending 
to the middle ear through the Eustachian tube. The peculiar 
nervous temperament of the individual, which predisposes to 
reflex neuroses, must be taken into consideration. 



CHAPTER XVI. 
DISEASES OF THE UVULA AND SOFT PALATE. 



Malformations. 
Bifid and Rudimentary. 
Elongation. 

Inflammatory Diseases. 
Acute Uvulitis. 
Chronic Uvulitis. 
Ulceration. 

Non-inflammatory Diseases. 
Adhesions. 
Neuroses. 

Hyperesthesia. 

Anesthesia. 

Paresthesia. 

Neuralgia. 

Spasmodic Contraction. 



Paralysis. 

Acute Bulbar Paralysis. 
Chronic Bulbar Paralysis. 
Apoplectiform Bulbar Paralysis. 
Herpes of the Fauces. 



BIFID AND RUDIMENTARY MALFORMATIONS. 

The most common anomaly of the uvular continuation of the 
soft palate is bifurcation more or less completely accomplished, 




Fig. 172.— Showing congenital absence of the hard and soft palates ; the Eustachian 
orifice shows plainly on the right side. 

though congenital absence or rudimentary development has been 
observed. Regarded by some authors as analogous to cleft palate, 
with an element of heredity, bifid uvula may exist as merely a 

413 



444 DISEASES OF THE UVULA AND SOFT PALATE. 

median furrow terminating at the tip of the uvula, or as a com- 
plete division of that organ into separate and distinct halves, 
which may be of unequal length. 

From a pathological standpoint this condition has practically 
no significance, except when interfering with speech or giving rise 
to cough by tickling the pharynx. This latter symptom will be 
more marked while lying down, or during the progress of an acute 
catarrhal process involving the upper respiratory tract. 

The treatment of bifid uvula under these circumstances should 
consist in a denudation of the inner aspect of the two parts under 
cocain anesthesia, by grasping each part in turn with a hemostatic 
forceps and stripping off the inner mucous covering with a teno- 
tome or finely pointed scissors. This brings two raw surfaces 
together, and complete union results. The contraction of the 
scar-tissue will shorten any previous elongation. Congenital 
absence of the hard or soft palate, or both, frequently occurs. Fig. 
172 shows the absence of both. 



ELONGATION OF THE UVULA. 

The assumption of an arbitrary length for the uvula in the 
healthy adult would appear ridiculous, yet for the purpose of 
diagnosis it may be considered safe to regard -| of an inch as a limit ; 
beyond this symptoms referable to the uvula may be looked for. 
Impingement of the normally situated uvula upon the tongue or 
epiglottis during inspiration, when it usually should be retracted, 
is another method of gauging abnormality. 

Etiology. — Congenital redundancy of tissue, general faucial 
relaxation due to anemia, partial paralysis following scarlet fever, 
diphtheria, and allied conditions, continued catarrhal inflammation 
of the nasopharynx, causing not only elongation, but chronic thick- 
ening, depression of the soft palate by growths or structural involve- 
ment above, thus forcing the uvula down, are the most frequently 
observed causes of the condition. . 

Pathology. — Except in the elongation due to chronic catarrhal 
inflammation, the diameter of the uvula is not increased, the length 
being augmented by the addition of white fibrous and yellow 
elastic tissue analogous to that found in the normal uvula, while 
the appearance and consistence of the mucous covering are influ- 
enced by the etiological factor underlying the condition. 

Symptoms. — A tickling sensation or feeling of irritation, giv- 
ing rise to efforts to free the fauces from an imaginary foreign 
body by " hawking " it up or by swallowing, are usually the first 
symptoms of an elongated uvula. A continuance of this irritation 
will in time produce a dry, irritating, persistent cough, aggravated 
on lying down, because of the dropping back of the uvula against 
the pharyngeal wall. 



ELONGATION OF THE UVULA. 445 

Further enlargement or increase of irritation may cause asth- 
matic or choking attacks, spasm of the glottis, chronic laryngitis, 
and impairment of the voice. 

Diagnosis. — With the facts in mind that the usual length 
of the uvula is rarely over -| inch, and that it should swing free 
of the tongue during inspection, the diagnosis is not difficult. 

Prognosis. — For the ordinary employment of the voice, elon- 
gation of the uvula usually augurs no ill ; but for the singer or 
elocutionist it may prove at first annoying, and, finally, absolutely 
distressing, because of impairment and final loss of the educated 
functions of the voice. 

Treatment. — Rational treatment of elongation of the uvula 
depends on the careful search for, and remedy of, the underlying 
cause. No local application, without removal of the cause, will 
effect a permanent cure ; but temporary arrest of the more prominent 
symptoms may be obtained by applying on a cotton-covered probe, 
every second or third day, such astringent solutions as nitrate of 
silver, 5 to 10 per cent., or 10 to 20 per cent, chromic acid. 

The relaxation due to anemia should be overcome, in part at 
least, by the internal administration of blood-making agents, such 
as iron or arsenic. For the paresis consequent upon diphtheria 
and allied conditions, strychnin should be pushed to full tolerance, 
and the electrical current employed. 

Catarrhal conditions or growth of the adjacent structures should 
be treated along the lines laid down under those particular subjects. 
Failure with these methods should suggest the forcible pinching 
of the tip of the uvula by means of the ordinary forceps or, better, 
by the use of the hemostatic forceps, taking care not to compress 
the tissue to the point of devitalization, the object being merely to 
set up inflammation, with subsequent organization and contraction. 
Should this procedure fail, recourse should be had to the removal 
of a portion of the tip of the uvula. In no case should the organ 
be amputated in its entirety, except for actual involvement by 
malignant disease. 

A number of instruments have been devised for uvulotomy — 
all severing the portion to be removed by one cut at a right or 
acute angle to the long axis of the uvula. The pain consequent 
upon leaving a denuded tip dangling in the way of food entering 
the esophagus, as well as a resulting clubbed uvula, I have obvi- 
ated by the following method, for which no special instruments 
are required. After rendering the uvula anesthetic by applying 
3 to 5 per cent, solution of cocain, the tip is grasped with a pair 
of ordinary straight forceps, exerting little or no traction, and a 
wedge-shaped portion, with the point of the wedge (see Fig. 173) 
up (the amount depending on the extent of elongation), is removed 
with a small straight bistoury, cutting from the center out. The 
denuded surfaces, coming in contact with each other, or held by 



446 DISEASES OF THE UVULA AND SOFT PALATE. 

sutures (see Fig. 173), rapidly unite, leaving a mere line of incision 
which is protected, while healing, from trauma or infection. Care 
should be taken not to remove too much tissue. The toilet of the 




l*%8*- 



Fig. 173.— Showing operation (uvulotorny) for shortening uvula, especially the club- 
shaped uvula, so as to avoid scar-tissue : o, line of incision ; b, sutures in position ; c, 
wound closed. 

wound consists in cleansing every three hours with an antiseptic 
alkaline solution, such as — 

1^. Sodii bicarbonatis, gr. viij (0.48) ; 

Acidi carbolici, gtt. j (.06) ; 

Cocainae hydrochloratis, gr. viij (0.48) ; 

Extracti hydrastis (colorless), fl^ij (7.5) ; 

Aquse, q. s. ad n\?j (30.).— M. 

A small piece of slippery-elm bark or gum arabic may be held 
in the mouth to allay the irritation. No solid food or irritating 
condiments should be allowed for at least forty-eight hours. 

Hemorrhage after uvulotorny, if the operation is properly per- 
formed, is usually but slight. Should, however, the bleeding be 
profuse, a curved needle threaded with double silk thread, having 
the ends of sufficient length to permit of tying outside of the 
mouth, is passed by means of the ordinary needle-holder through 
the uvula from side to side just above the cut surface, and each 
thread tightened enough to stop the bleeding. Sloughing with 
secondary hemorrhage can be avoided by removing the ligatures 
in a few hours after clot-formation has taken place. 

INFLAMMATORY DISEASES. 

ACUTE UVULITIS. 

Synonyms. — Edema of the uvula ; Acute infiltration. 

Etiology. — A uvula of a size longer than normal naturally 
increases the liability to injury or acute inflammation. An acute 
uvulitis often accompanies the rachitic diathesis and digestive 
derangements. Extension of inflammation from adjacent struct- 
ures will give rise to a similar condition, as a swollen, boggy 
uvula is often observed during an attack of quinsy or acute 
pharyngitis. Trauma due to ingestion of irritants, such as very 
hot liquids or acids, will give rise to an acute inflammation with 



ULCERATION. 447 

edema. Often the factor underlying the condition cannot be 
ascertained. 

Pathology. — Inflammation goes on to its second or exudative 
stage, and the pathological condition of serous infiltration of the 
muscular and mucous structures occurs more rapidly in this organ 
because of gravity combined with lack of bony or muscular support. 

Symptoms. — The first symptom noticed will in all probabil- 
ity be a feeling as though there were a foreign body tickling and 
irritating the fauces and, later, the pharynx. Efforts at expulsion 
or ineffectual attempts at swallowing will follow. A cough will 
soon begin, and, in proportion to the extent of the infiltration, 
dyspneic symptoms, with difficulty and pain on swallowing, will be 
complained of. Inspection will show a swollen, boggy, sometimes 
sacculated mass, partly or wholly occluding the oropharyngeal 
opening. 

Treatment. — Multiple puncture with a small sharp-pointed 
bistoury or double-cutting aspirating needle is the best means of 
depletion. The short curve of a double retractor should be held 
behind the uvula to prevent puncturing the pharynx, and from 10 
to 20 incisions should be made about the dependent portion of the 
organ to about -| inch in depth. In this way sufficient serum will 
be drawn off to give the blood-vessels their normal tonicity and 
enable them to go on to complete removal of the exudate. Spray- 
ing with ice water will afford much comfort to the patient and aid 
in depletion. The after-treatment consists in thorough cleans- 
ing with an alkaline solution, and the daily application of a mild 
astringent, such as tannin 3 to 5 grains, or sulphate of copper, 
1 to 3 grains to the ounce of water. 

CHRONIC UVULITIS. 

The acute inflammatory process involving the uvular mucosa, 
instead of terminating in return to normal, may continue and con- 
stitute the condition known as chronic uvulitis. It is almost 
universally found associated with chronic pharyngitis or chronic 
nasopharyngitis, and is dependent in great measure on an inten- 
sification of the causes underlying these processes. 

The symptoms are usually of such trifling moment as to call 
for no special attention, and the treatment of the associated condi- 
tion, as a rule, relieves the uvular involvement. 

Either acute or chronic abscesses may occur in the tissues of 
the soft palate or uvula, although of rare occurrence. 

ULCERATION. 

Ulceration of the uvula without involvement of adjacent struct- 
ures is comparatively rare. By reason of its dependent position 
and the fact that it hangs in the way of food or drink entering 



448 DISEASES OF THE UVULA AND SOFT PALATE. 

the alimentary canal, it may occasionally be the original site of a 
simple ulcerative process. These small ulcers cause consid- 
erable pain on deglutition, and should be touched with a solid 
stick of nitrate of silver, when the majority of them promptly 
heal. 

In all cases of postnasal catarrh in which the constant presence 
of secretion just above the palatine folds is complained of, a 
careful rhinoscopic search of the posterior aspect of the uvula 
should be made for minute points of ulceration giving rise to 
this symptom. If found, they should be cleansed with an alkaline 
detergent solution, carefully dried, and a stimulating powder, such 
as salicylic or boric acid, 15 to 30 grains to the ounce of stearate 
of zinc, should be dusted on. 

Ulceration of the uvula, primarily or by extension from adja- 
cent structure, occurs in tuberculosis, syphilis, or any of the specific 
inflammatory processes. The appearance of these ulcerated areas 
on the uvula does not differ in the main from that observed in 
other localities. The tubercular involvement may appear as small 
wart-like excrescences which go on to ulceration, so arranged that 
a peculiar club-like formation is given to the uvula. 

Syphilitic ulceration shows evidence, in places, of local hemor- 
rhage somewhat peculiar to this type of ulceration. These ulcer- 
ated areas should be carefully cleansed with hydrogen peroxid, 
followed by an alkaline antiseptic solution, such as boric acid 10 
grains to the ounce, or — 

ly. Sodii biboratis, 

Sodii bicarbonatis, da gr. viij (.48) ; 

Toluol, gtt. j to v (.06-.3) ; 

Glycerini, gtt. xv (.9) ; 

Aqua?, q.s. ad fl^j (30.).— M. 

The appropriate constitutional treatment is given under the 
Nasal Manifestations of these various conditions. 

Mycosis of the fauces may be extensive, may involve the uvula, 
and presents its characteristic appearance of small, pointed masses 
projecting from the surface of the mucous membrane — opaque, 
milky white in color, moist and soft. This evidence of the 
involvement by the leptothrix is treated more fully under 
Pharynx. 

The uvula may be the site of bacteritic invasion, either pri- 
marily or by extension. The false membrane generated by the 
action of the Bacillus diphtherias or that due to streptococci is 
seen on the uvula, but differs in no way as to symptoms or treat- 
ment from that found elsewhere. Before it is seen in the throat 
it would be advisable in all cases of suspected diphtheria to make 
a careful rhinoscopic examination of the posterior aspect of the 



CONGENITAL INSUFFICIENCY OF THE PALATE. 449 

uvula, as this locality seems to be a favorite site for the Klebs- 
Loffler bacillus. 

Emphysema of the uvula and soft palate may result from acci- 
dent or carelessness in catherization of the Eustachian. tube. The 
treatment consists in immediate multiple puncture. 

CONGENITAL INSUFFICIENCY OF THE PALATE. 

This condition is a congenital malformation in which the soft 
palate does not effect the physiological closure of the nasopharynx 
from the oral cavity. As a result there is rhinolalia aperta. This 
condition of failure of closure may be due to submucous cleft or 
muscular insufficiency of the palate. In the submucous cleft there 
is usually beneath the intact mucous membrane a notch or gap in 
the posterior part of the hard palate, and the imperfect union in 
the median line of the muscles of the two halves of the soft palate. 
There is also usually a shortening of the hard palate. In the sub- 
mucous cleft the epithelial covering of the palatal processes may 
unite across the middle line, but development has been interrupted 
before the mesoblast contained in these processes has effected a 
perfect union. 

The submucous cleft, then, may be sufficient or insufficient, 
according as rhinolalia aperta is absent or present. The conditions 
which would determine this are : The .length of the hard and soft 
palate, the degree and mode of elevation of the soft palate, the 
depth of the pharynx, and also the efficiency of the approximation 
of the palatal pharyngeal muscles. 

The muscular insufficiency of the palate shows the imperfect 
elevation of the palate during phonation. In the muscular in- 
sufficiency there may or may not be interrupted development of 
the hard palate, although in the majority of cases there is the 
notching of the hard palate, and the non-union either partial or 
complete. In muscular insufficiency there is nearly always some 
congenital involvement of the blood and nerve supply. Where 
there is no cleft, but slight muscular insufficiency, there is defec- 
tive speech. In all cases of defective speech the perfect muscular 
activity of the muscles of the soft palate should be carefully studied. 
In muscular insufficiency there is always irregularity in the ante- 
rior and lateral measurements of the pharynx. The defect of speech 
is, of course, equally true, but more marked, in the submucous 
insufficiency. 

In nearly all cases of defective palate, either hard or soft, there 
is irregularity of the formation of the facial contour and of the 
cavity of the mouth. As a rule, the mental and physical develop- 
ment of such cases is below par. This may be explained owing to 
the fact that on account of the defectiveness of the palate the taking 
of food is not done in the physiological way, and the patient is illy 
nourished. The defect itself has a tendency to make the child 

29 



450 DISEASES OF THE UVULA AND SOFT PALATE. 

backward, so that the mental development, as a rule, is not so 
rapid, although in some instances I have seen unusually bright 
children thus afflicted. 

Very little can be done for this condition other than the use of 
Gutzmann's method of massage and stretching of the soft palate. 

NONINFLAMMATORY DISEASES. 

ADHESIONS. 

As the result, especially of syphilitic ulceration of the structure, 
the soft palate and its lateral and central continuations may be the 
seat of a great variety of abnormalities. Perforation of the soft 
palate, half-arches, and even the hard palate, have been often 
reported. The ulceration may extend to or from the nasal side to 
its opposite. These openings from the oral to the nasal cavity 
give rise to symptoms varying according to their location and 
size. As a rule, alteration in the voice, giving it a curious nasal 
twang, and escape of fluids through the nose are the usual con- 
comitants. If the condition is seen before healing has taken 
place, the ulcers should be treated on the lines laid down under 
Syphilis (page 152). For perforation of the hard palate, ordinary 
chewing gum can be moulded into shape and worn instead of the 
various appliances, as being less expensive and cleaner. 

Another phase of deformity consequent upon syphilis is union 
of these and adjacent parts. Given an ulcer of the soft palate, 
uvula, or faucial pillars with attrition upon the lateral or posterior 
pharyngeal walls, and with a tendency to cicatrization, the result 
will be adhesion, contraction, and abnormality. 

Bizarre alterations of the normal topography, with peculiar 
stellate cicatrices, are characteristic of syphilis. No other condi- 
tions, except those consequent upon extensive burns or lupus, in 
any way simulate it. Adherence of the uvula to any of the four 
half-arches, union of the pillars one to the other, junction of the 
velum in whole or in part with the pharyngeal walls are but types 
of the varied combination of deformity that may be seen. Num- 
bers of cases of almost entire closure of the nasopharynx by the 
adhesion of the soft palate to the pharynx have been reported. 
Fig. 174 is a drawing of the throat of a patient operated on in 
1876 by Dr. W. W. Keen for complete adhesion. The drawing 
shows the result twenty-two years after. Complete congenital occlu- 
sion is of rare occurrence. I have seen one such case, which was 
referred to me by Dr. Leidy, of Flemington, N. J. The patient 
was unmarried, and had spent an uneventful and irrelevant medi- 
cal life, denying wholly any syphilitic infection. Some years ago, 
at about the age of fourteen, the present condition of affairs was 
detected, and she avers that she is positive that since that time 



ADHESIONS. 



451 




Fig. 174.— Showing a case in which there had been syphilitic adhesion of the soft palate. 
The appearance now shows the adhesion freed (Keen). 

there has been no communication whatever between the naso- 
pharynx and mouth ; while in favor of the condition having existed 




Fig. 175.— Showing adhesion of the soft palate, with complete obstruction of the naso- 
pharynx. 

prior to that time — in fact, having been congenital — may be adduced 
the fact that the narrow, slit-like nares showed a lack of breathing 



452 DISEASES OF THE UVULA AND SOFT PALATE. 

function dating back to the formative period, and the sensitive- 
ness of the membrane also argued against scar-tissue. Breathing 
has been purely by the mouth, and she made application for relief 
from impairment of her hearing, which had grown gradually 
worse. The voice lacked nasal resonance. The patient's general 
expression was of the mouth-breather type, though not markedly 
so. The lips held partly open show the teeth to be in poor con- 
dition (Fig. 175), the upper central incisors notched after the 
manner described by Hutchinson. Inspection of the oral cavity 
showed entire absence of the uvula, which is lost in a veil of tis- 
sue extending from the posterior border of the hard palate to the 
pharynx, cutting off all communication with the nasopharynx (Fig. 
175). This wall of tissue was somewhat paler than the surround- 
ing structure, filled with peculiar fibrous-looking bands running at 
all angles. The sensation of every part of the structure was undi- 
minished, there being rather a hypersensitiveness than the opposite. 

An attempt was made to establish a communication between 
the mouth and nasopharynx. This was done under chloroform, 
and, when the incisions were made to establish a new velum, it 
was found that the entire nasopharynx was blocked up with a mass 
of tissue, at least 1 inch in thickness, through which an opening 
had to be forced to the anterior nares. Normal topography was 
entirely obliterated, there being no Eustachian openings palpable 
or discernible. A false (in the true sense) palate was dissected 
loose and allowed to swing free in the mouth. In order to prevent 
a reuniting of this structure with the pharyngeal wall, I passed — 
after the manner suggested to me by Dr. W. W. Keen as having been 
pursued by him in a case operated on in 1876 with perfect success 
(Fig. 174) — a thread, double-leaded with shot, through this tissue 
from behind and, failing in my attempts to tie on the teeth as 
Keen had done, passed the needle through the cartilaginous sep- 
tum of the nose and made the thread fast there. Despite constant 
douching through the orifice on the part of the hospital attendants, 
the opening could not be kept patulous, and, after a second estab- 
lishment of free communication with subsequent failure, I aban- 
doned the attempt and discharged the patient at least no worse 
than before the operation. I quote this case in detail in order to 
impress the fact that non-interference should be the rule in cases 
of this character, even though no syphilitic history is obtainable, 
and unless the closure threatens life. It might be possible to keep 
the opening patulous by the daily passage of a graduated bougie, 
yet such a passage would be of little respiratory use. 

In cases, however, in which the occlusion of the nasophar- 
ynx is merely due to the adhesion of the soft palate to the phar- 
yngeal wall, and in which there is no solid mass of fibrous tissue 
involving the entire nasopharynx, relief can be afforded the 
patient by resecting loose the soft palate from the pharyngeal 



NEUROSES. 453 

wall, and the two surfaces can be kept apart by the shot or some 
similar method until healing has taken place. I have seen a 
number of such cases at my clinic at the Jefferson Medical 
College Hospital, but the cases in which the occlusion is fibrous 
and involves the whole nasopharynx are exceedingly rare. 

NEUROSES. 

Alterations in the normal sensitiveness, such as hyperesthesia, 
anesthesia, and paresthesia of the soft palate and its appendages, 
have been described. I am inclined to the belief held by Bos- 
worth, that paresthesia is dependent upon abnormality in adjacent 
structure, or upon a general systemic involvement evidenced in 
part in this locality, and should be treated accordingly. 

Neuralgia of the soft palate may be seen in hysterical females 
as a local manifestation of general involvement, may be associated 
with pharyngitis follicularis or lateralis, or may be due to morbid 
conditions of the adjacent tonsillar structure. Tonics, such as 
iron, phosphorus, strychnin, and quinin, are indicated, as well as 
proper local treatment of the offending structures. 

A Spasmodic contraction of the muscles of the fauces, par- 
ticularly of the levator palati, occurs occasionally. The soft 
palate, drawn rapidly against the pharynx, is as rapidly released, 
giving rise to a clicking sound. This choreic involvement of the 
palate continues for a short time, when the spasm ceases. As of 
chorea no definite cause can be assigned. Look carefully for any 
abnormality either in the nose, nasopharynx, or mouth, which 
might reflexly cause the condition ; at the same time administer 
general tonics, such as iron and quinin in conjunction with arsenic, 
and regulate the diet, bathing, clothing, and exercise. 

Paralysis. — Paralysis of the muscles of the soft palate or 
uvula may be consequent upon any form of inflammatory lesion of 
the fauces, particularly diphtheria, may be central or local, or may 
be due to a general blood-involvement. 

The symptoms of this condition are impairment of degluti- 
tion, with a tendency for fluids to enter the nasal cavity. The 
voice is thick and loses its nasal resonance. Articulate speech is 
difficult. The saliva collects in the mouth because of the diffi- 
culty in expectoration. The paralysis may involve one or both 
sides, and the pendulous palate, irresponsive to stimuli, renders 
the diagnosis comparatively easy. If the paralysis is unilateral, 
the healthy muscles will draw those affected toward the sound 
side. 

The condition may persist for weeks and even months, espe- 
cially if due to diphtheria, yet the outlook for an ultimate cure is 
good, if strychnin be pushed to its full limit and the electrical cur- 
rent be assiduously employed. Eliminating the class of paralysis 



454 DISEASES OF THE UVULA AND SOFT PALATE. 

just considered, as well as paralytic involvement of the levator 
palati and azygos uvula? muscles, which are supplied from the 
facial nerve, there remain to be treated paralyses due to bulbar 
lesion. These may be divided, as to cause, into those due to acute 
and chronic bulbar myelitis, hemorrhage, softening, embolism, 
tumors, basilar meningitis, and endarteritis. 

Acute Bulbar Paralysis. — This is extremely rare and fatal, 
characterized by sudden onset and rapidity of paralytic develop- 
ment. Commencing with headache, giddiness, and possibly vom- 
iting, weakness and unsteadiness of gait soon follow. Conscious- 
ness is preserved, but dysphagia and difficulty in articulation are 
soon noticed and rapidly grow more pronounced. Cardiac involve- 
ment and death supervene in from four to ten days. 

There is no effectual treatment. 

Chronic Bulbar Paralysis. — On account of degenerative 
changes in the bulbar nuclei in the medulla there may insidiously 
develop a disease described by Duchenne as labioglossopharyngeal 
'paralysis. Beginning with a slight sensation at the back of the 
neck, a hesitancy in speech or articulation soon follows. Difficulty 
of deglutition later is noted, due to palatal paralysis. Mastica- 
tion is interfered Avith because of the inability of the tongue to 
manage the food, the tongue having the appearance of being 
enlarged. The involvement of the larynx is marked. The dis- 
ease progresses slowly, but surely, to a fatal termination in from 
one to five years, death being due to starvation. 

Apoplectiform Bulbar Paralysis. — As the outcome of 
hemorrhage, embolism, endarteritis, or softening affecting the gan- 
glia situated in the floor of the fourth ventricle, there may arise 
sudden apoplectiform paralysis of the palate, related structures, 
and larynx, which, though occasionally going on to fatal termina- 
tion, is, as a rule, transitory. Accurate localization of the lesion 
is usually a matter of much difficulty. 

The symptoms, as a rule, supervene suddenly during sleep, 
and consist, when the patient wakes, in malaise, disinclination to 
move, dizziness, and occasional headache with vomiting. Swal- 
lowing is difficult or impossible. There may be slight transitory 
impairment of the extremities. Paralysis of the palate may involve 
one or both sides, causing the usual train of symptoms. 

The outlook is not especially grave, and the treatment should 
consist in the proper management of the symptoms. 

Paralysis due to tumors, meningitis, cysts, or abscess — tuber- 
culous or syphilitic — involving the medulla comes on, as a rule, 
slowly, usually involves other structures whose centers are situ- 
ated close to those of the palate, and is attended by symptoms too 
varied to be dwelt upon at length. 

It is to be borne in mind that, while describing the above 
affections, the paralytic involvement of the parts under discussion 



NEUEOSES. 455 

has been especially dwelt upon, and much that would be essential 
in a complete portrayal of the entire disease has of necessity been 
omitted. 

Herpes of the Fauces. — Occurring occasionally and usually 
involving the uvula and soft palate, herpes has been observed. 

The affection is probably due to circumscribed inflammation 
originating in the peripheral terminal nerve-filaments. The erup- 
tion occasions a certain amount of discomfort, sometimes pain, and 
an intolerable itching referred to the fauces. Inspection of the 
region reveals small papules, purplish-red in color, markedly con- 
trasting with the surrounding pink of the normal mucosa. They 
usually occur on one side only, and may be scattered irregularly 
over the membrane or arranged in circular forms. The eruption 
as a whole, as well as each individual lesion, is not usually per- 
sistent, but after lasting from five to ten days disappears, to recur 
after a week or so, occasionally remaining absent for months. 

On the assumption that the affection is dependent largely upon 
underlying constitutional causes, the treatment should be ad- 
dressed to the general system, and recourse should be had to the 
employment of cod-liver oil, the hypophosphites, and lactophos- 
phates of lime, iron, and arsenic. Locally, for the pain and dis- 
comfort, anesthetic or sedative applications should be made. The 
following may be applied once daily on a cotton-covered probe : 

fy. Menthol, 

Cocaina?, da gr. v (.3) ; 

Vaselini (carbolized), ij (30.). 

and a gargle made up as follows, given to the patient to use when 
necessary : 

fy Thymol, gr.j(.06); 

Menthol, gr. xv (.9) ; 

Extract! hydrastis (colorless), fl^ss (15.); 
Extracti hamamelidis (aqueous), 
Aqua? cinnamomi, ad fljij (30.). — M. 



CHAPTEE XVII. 
DISEASES OF THE TONSILS. 

1. Pharyngeal. 3. Lingual. 

2. Faucial. 4. Laryngeal. 

Instead of considering diseases of the tonsils purely as to 
their location, they are of sufficient importance, owing to their 
clinical significance, to be classed under a separate chapter. While 
the various tonsillar structures are not related from a physiological 
standpoint, yet from a pathological standpoint the lesions are fre- 
quently associated. 

The pharyngeal tonsil (Fig. 1), which lies in the posterior wall 
of the nasopharynx, is composed of lymphatic or adenoid tissue 
held together by fine trabecule of connective-tissue elements. It 
is more of a conglomerate gland than strictly racemose. The 
mucous-membrane surface is rather thin, covered with one layer 
of columnar epithelium, which in some cases is ciliated. The 
gland contains numerous follicles, and the whole structure is highly 
vascular. It is normally present in childhood, and should un- 
dergo atrophy from the twelfth to the twentieth year of life. 
Even in its normal condition the surface may be lobulated. 
When the gland-structure involves the orifice of the Eustachian 
tube, it is known as the tubal tonsil (Fig. 1). This same term is 
applied to the gland-structure in the Eustachian orifice caused by 
diseased process in the pharyngeal tonsil. 

The faucial tonsils (Fig. 1) are two in number, lying between 
the pillars of the fauces on either side. They are composed of 
lymphoid structure containing numerous follicles and crypts, are 
highly vascular, and are covered with mucous membrane lined 
with squamous epithelial cells. The secreting and absorbing prop- 
erties of the tonsils make them an important factor in disease. 

The lingual tonsil (Fig. 1) consists of a series of lymphoid 
masses located at the base of the tongue, involving its posterior 
one-fourth. 

The laryngeal tonsil (Fig. 1) is made up of small lymphoid 
nodules within the ventricle of the larynx, and can only be 
demonstrated macroscopically when in a diseased condition. 

Within the nasal orifices, underneath the mucous membrane, is 
situated a mass of adenoid tissue somewhat diffused, but here and 
there aggregated as lymph-follicles. These follicles are known as 
the nasal tonsil, 

456 



PHARYNGEAL TONSIL. 457 

Luschka's bursa is a depression or crypt situated in the lower 
part of the pharyngeal tonsil. It is much larger than the neigh- 
boring crypts, and has a dilated extremity or pouch. 

PHARYNGEAL TONSIL. 

Synonyms. — Luschka's tonsil ; Adenoid vegetations ; Discrete 
tonsils ; Epipharyngeal tonsil ; Third tonsil. 

This gland is a physiological structure, attention being directed 
to it only when it becomes enlarged, thereby causing obstruction. 
As this tissue usually atrophies before adult life, attention is gener- 
ally directed to this structure in childhood. Whether the enlarge- 
ment is congenital or occurs soon after birth matters little, as the 
main symptom demanding relief is the obstruction to nasal respi- 
ration, which, if unimpaired as the process of development goes on, 
has much to do with the regular formation and contour of the face. 
The respiratory act through the nose, as well as the action of the 
muscles controlling the nasal orifices, are factors of importance in 
controlling the size of the nasal cavity. If this function is inter- 
fered with by any obstructive lesion, as would occur in adenoid 
vegetations, and that obstruction is allowed to remain until the 
bony nasal framework has become firmly united, the capacity for 
nasal breathing is permanently fixed ; and even should the gland- 
structure causing the obstruction be removed, while its ablation 
may relieve the nasopharyngeal symptoms, it cannot possibly 
increase nasal respiration, other than by lessening the engorgement 
of the submucosa subsequent to such obstruction. This fixity 
of the bones of the face may leave the individual a confirmed 
mouth-breather. The effect of impaired respiration due to post- 
nasal obstruction is also manifested in an ill-formed superior max- 
illary arch, with marked irregularity in the arrangement of the 
teeth. This irregular development is largely caused by the repeated 
contraction of the muscles controlling the nasal orifices, necessitated 
by the forced nasal inspiration and snuffling. By this drawing 
down of the facial muscles the upper jaw is retracted, and the 
contour of the upper arch is altered. The hard palate, then, 
instead of forming a perfect dome, has its anterior portion tilted 
out and its upper portion, at the base of the nose, drawn in. With- 
out this interference the pressure of air within the natural passage 
counterbalances that upon the external surface, and normal develop- 
ment takes place. This, of course, will occur only when the 
obstruction takes place in early life, before the bones are firmly 
united. This irregularity in the arch will produce unevenness in 
the development of the teeth, causing their irruption high up in 
the alveolar process, or, if placed in the arch, they will be crowded 
and irregular. If the irruption occurs high up, it will add to the 
protrusion of the upper lip, increasing the facial deformity so 



458 DISEASES OF THE TONSILS. 

characteristic of adenoid obstructions. "Inherited tendency" to 
adenoids is often, in reality, the inherited family nose, children with 
the narrow, slit-like orifice being more prone to thickening of the 
adenoid structure than those having a wide-open nostril. As a 
rule, this postnasal obstruction due to adenoids interferes with 
both nostrils, yet occasionally it is one-sided. I have seen several 
such cases, and unless the obstruction be removed early in life, 
irregular, one-sided development and uneven facial contour is 
observed. The condition then may precede and be the cause of 
anterior nasal stenosis, or the latter condition may be a factor in 
the enlargement of the adenoids. 

The term adenoid vegetations includes enlargement not only of 
the pharyngeal tonsil, but also of the closed follicles situated in the 
mucous membrane of the posterior surface of the vault and the 
posterolateral walls of the nasopharynx. Frequently the question 
of recurrence of the pharyngeal tonsil or tissue, ordinarily known 
as adenoid, is discussed. I think, beyond any question, there is a 
tendency not of recurrence, but of continuation of the growth. 
In some individuals the gland mass is quite superficial and can be 
removed in its entirety, while in others this peculiar conglomerate 
gland-structure appears to be imbedded in the mucous membrane ; 
and while the nasopharynx may be thoroughly cleared of the 
growth, and nasal respiration thoroughly and freely established, 
there may be, in certain lymphatic types of children, a tendency 
for this gland-structure to continue its growth, or if a portion of 
the gland is allowed to remain in the nasopharyngeal wall it may 
continue enlarging until it reaches a sufficient size to cause some 
nasal obstruction. This is true in cases in which the gland is 
removed before the fifth year. My own experience is that an 
occurrence of either of these conditions has been very rare. 

Etiology. — Attention is directed to the glandular enlargement 
most frequently between the ages of three and ten years, although 
it may begin before the third year, or may even exist at birth. 
From the tenth to the fifteenth year the structure undergoes 
physiological atrophy. This may occur even if the tissue is not 
enlarged, as well as when it is the subject of pathological changes.' 
Sex is not associated as an etiological factor. 

The fact that enlargement may occur in several children in 
the same family involves the question of heredity only as to the 
inherited family nose or lymphatic temperament. In constitutional 
dyscrasise, as in the syphilitic or tubercular condition, there is a 
tendency to general glandular involvement, which is increased by 
the fact that from the lessened physiological resistance and dimin- 
ished vascular tone there is a tendency to sluggish circulation in 
lax structure, especially the mucous membrane. This will tend to 
engorgement and watery infiltration, more marked where the 



PHARYNGEAL TONSIL. 459 

lymph-channels are numerous. Any condition bringing about 
anemia will produce this phenomenon. 

Climate is an important exciting factor, the enlargement being 
more common in damp climates or in locations in which there are 
sudden changes of temperature. This is especially true in the 
lymphatic type of individuals, as they are more affected by sudden 
thermometric alterations. The disease seems to be more prev- 
alent among children in the city than in the country, which 
may possibly be explained by the fact that children living in rural 
districts are healthier and are not constantly breathing a dust-laden 
atmosphere, a source of continuous irritation. Irritating vapors, 
too, may be an exciting factor in bringing about engorgement or 
inflammatory changes in the anterior and posterior nasal chambers. 
The relation and association of adenoid vegetations with the 
various forms of rhinitis is quite marked. This is especially true 
in purulent rhinitis and the infectious inflammations, though it 
must be granted that " adenoids " may exist prior to the inflam- 
matory condition of the nasal mucosa, and that owing to this 
obstruction to nasal breathing and the tendency created by them 
to the accumulation of secretion within the nasal chambers, a 
lowering of physiological resistance is established, and the likeli- 
hood to infection is increased. On the other hand, it may be argued 
that in a pre-existing infection of the anterior nasal cavity there is 
a discharge of the irritating material into the nasopharynx, which 
will excite inflammatory processes in the gland-structure. 

As an exciting factor, irritating materials coming from the 
circulatory system, as in the uric-acid diathesis, may bring about 
enlargement of the postnasal gland-structure. This, however, is 
always associated with inflammatory conditions of the adjacent 
mucosa, as well as of the other mucous-membrane tracts. Enlarge- 
ment of the pharyngeal tonsil and associated gland-structure of the 
nasopharynx does not necessarily mean hypertrophy or hyperplasia. 
The gland-structure may be enlarged by a natural increase in 
structure, due to increased blood-supply, and is in reality hyper- 
plastic. This structure will be rather Arm, although not dis- 
tinctly fibrous. Again, there may be enlargement of the pharyn- 
geal tonsil as the result of inflammatory processes. The organi- 
zation of this inflammatory material will give rise to a firmer and 
more fibrous mass in the nasopharynx. On the other hand, the 
tonsil may be increased in size as a result of interference with 
systemic circulation, bringing about reflex phenomena in structures 
remote from the site of the lesion. For example, it is a well- 
known fact that cyanotic conditions occurring in the liver, kidney, 
or lung will produce cyanosis in the mucous-membrane tract ; that 
intestinal irritation with chronic constipation will produce engorge- 
ment of the upper respiratory tract, especially the nasal mucous 
membrane. In children, then, with intestinal irregularities, such 



460 DISEASES OF THE TONSILS. 

as obstruction, constipation, or irritation produced by intestinal 
worms, there will result turgescence and cyanotic congestion, with 
watery infiltration of the nasal and postnasal structures. The 
pharyngeal tonsil in childhood is a normal structure, and its 
enlargement as described above is frequently mistaken for an 
increase in cellular elements, when in reality it is only the normal 
structure enlarged by fluid-distention, either intra- or extravascu- 
lar. I have seen many cases of postnasal obstruction in children, 
which on examination would seem to indicate immediate surgical 
interference, in which complete relief was obtained by the correc- 
tion of the intestinal irregularities, the most common of which I 
believe to be due to intestinal worms. Enlargement of the pharyn- 
geal tonsil may be associated with cleft plate and also enlarge- 
ment of the faucial and lingual tonsils. Such conditions are allied 
processes rather than etiological factors. Sudden acute inflamma- 
tory processes are often observed in the pharyngeal tonsil, and 
in children there is sometimes observed a sudden rise of the tem- 
perature, the child is peevish and irritable, with no clearly defined 
symptoms of any localized or systemic process. The child is 
usually treated expectantly, given purgatives and some simple 
febrifuge, and in from twenty-four to thirty-six hours the attack 
has entirely subsided. In many of these cases the symptoms were 
produced by inflammatory and probably slightly infectious proc- 
esses of the pharyngeal tonsil. 

Pathology. — The microscopical examination of the normal 
pharyngeal tonsil shows that it does not dhTer from other gland- 
structure of the same type ; that it is made up of fine trabecule 
of wavy connective tissue which hold in position nests of lym- 
phatic cells. The surface of the gland is covered with mucous 
membrane in which the basement membrane is ill-formed and not 
always demonstrable. The layer of epithelium is usually single, 
the cells being of the columnar variety and irregularly ciliated. 
However, in the enlarged or inflammatory tonsil this epithelial 
structure varies, when there may be several layers of epithelial 
cells of the pavement variety, and the basement membrane will be 
more distinct. 

Pathologically, we really have to deal with four different vari- 
ties of enlargement of the pharyngeal tonsil. There is the soft 
variety (Fig. 185), which appears as a smooth, semi-fluctuating 
mass that spreads over almost the entire nasopharynx ; it is 
largely influenced by atmospheric changes and the physical condi- 
tion of the child. This variety is composed almost entirely of 
the lymphoid structure, is very friable, is covered with a thin 
layer of epithelium with ill-formed basement membrane and sub- 
mucosa. The structure is so soft and friable that it can easily be 
broken up by pressure with the finger. The enlargement seems to 
be due to an overdevelopment of lymphoid structure. 




Fig. 176.-Section of soft adenoid growth from a child (author's specimen). 




Fig. 177.— Section showing tne fibrous 



adenoid from an adult (author's specimen). 



PHARYNGEAL TONSIL. 461 

In another variety, which might be called edematous or cyan- 
otic, there is a very little increase in the actual gland-structure, 
but the enlargement is due to venous stasis and edema produced 
by leakage from the vessels. This is the variety that is directly 
associated with intestinal irritation and irregularities in systemic 
circulation, most commonly observed in children who are suffering 
from some form of intestinal parasites. The structure is smooth 
and tense, although easily compressible. 

In the hard or hyperplastic variety there is an increase in. the 
lymphoid structure, with a decided overgrowth in the connective- 
tissue element. The mucous-membrane lining is well formed, and 
there are usually several layers of epithelial cells. The surface is 
more lobulated, although smooth to the touch. 

Another hard variety (Fig. 186) is that which follows inflam- 
matory lesions of the lymphoid structure, in which there is inflam- 
matory organization in the connective-tissue element, followed by 
slight contraction. This condition is usually secondary to inflam- 
matory lesions of the nose and nasopharynx, or may be brought 
about by thermocautery. In the inflammatory stage the obstruc- 
tion will be more marked, due to the edema and inflammatory 
congestion. 

The macroscopical appearance of these conditions is a varying 
one, depending entirely on the stage of the lesion. Owing to the 
small nasopharynx in children, it is impossible to obtain a good 
view by posterior rhinoscopy. A better idea of the structure can 
"be obtained by digital examination. This can be done by carefully 
sterilizing the index finger of the left hand ; then having the child 
open its mouth, the index finger of the right hand is placed 
beneath the jaw, while with the thumb of the same hand the cheek 
is pressed in between the teeth. This makes a good mouth-gag 
and prevents the operator's finger being bitten. 

Frequently the gland-structure just behind and parallel to the 
posterior lateral pillars is enlarged, usually secondary to enlarge- 
ment of the pharyngeal tonsil, and will, as a rule, disappear after 
the relief of the enlarged tonsil. Much of the so-called recur- 
rence of gland-structure after removal is due to a continuation 
of the enlargement of the structure left instead of recurrence from 
the original site of removal. As a rule, the physiological pharyn- 
geal tonsil atrophies before the fifteenth or sixteenth year of age. 
If, however, it has been the site of hyperplastic or inflammatory 
change, it may persist into adult life or even old age, and be the 
source of constant irritation ; it is always associated with anterior 
and posterior rhinitis, a condition which was observed in a man 
twenty-seven years of age. 

Symptoms. — The clinical symptoms of adenoid vegetations 
are very much the same as those found in any nasal or postnasal 
obstruction, except that they are more pronounced and more likely 



462 DISEASES OF THE TONSILS. 

to produce permanent alteration in adjacent structures. The most 
characteristic is the peculiar facial expression, or rather the peculiar 
expressionless face, which is caused by the loss of the labionasal 
fold ; others are the protruding upper lip with the receding chin ; 
the broadening of the bridge of the nose, which is partially due to 
the swelling of the superficial structures brought about by interfer- 
ence with the venous circulation. The mouth is usually open, or, if 
the lips are closed, the lower jaw hangs, giving to the child a pecul- 
iarly stupid look. The mental hebetude and aprosexia, or inability 
of the patient to concentrate attention, are the result of a number 
of conditions rather than of any one special cause. As the condi- 
tion is usually associated with deafness, some of the dulness is 
explained by inattention brought about by inability to hear general 
conversation, making the child indifferent and listless. The child 
complains of being tired, and is often irritable, peevish, and bad- 
tempered ; while the mouth-breathing causes restless nights, with 
subsequent impairment of general health, which in itself will cause 
impaired activity. Cohen and Allen have called attention to the 
fact that possibly the dull mental condition is due in some cases to 
alteration in the circulatory relation between the brain and naso- 
pharynx, either lymphatic or vascular. The deleterious effects of 
mouth-breathing cannot be overestimated. When the postnasal 
obstruction is only slight and when the nasal breathing during the 
day is only slightly obstructed, it may become more marked at night ; 
in fact, the child may be a night mouth-breather, and the only 
symptom complained of during the day will be irritation in the 
pharynx and larynx, the real cause of which may be overlooked. 
This postnasal obstruction interferes with the free passage of 
air through the nose, and permits of accumulation of secretion 
and the lodgement of dust within the nasal cavity, thereby causing 
irritation and setting up an inflammatory condition of the anterior 
nares, which in turn aggravates the postnasal tissue. A suitable nidus 
for the proliferation of bacteria is thus established, and may lead to 
the invasion of the accessory sinuses. This irritation also lessens the 
resisting power of the membrane by destroying the cilia of the epi- 
thelium. It is also to be borne in mind that this direct mouth- 
breathing will produce irritation of the pharyngeal and laryngeal 
structure, as the inspired air is not properly moistened or freed 
from dust, nor is the temperature altered before reaching the 
bronchial or lung structure. As a complication, then, there will 
usually be spasmodic cough, with a constant tendency to take 
cold ; the child may be subject to attacks of laryngismus stridu- 
lus, croup, and frequently asthma. There may be associated 
deformities of development, owing to imperfect breathing, such as 
narrowing of the chest, the peculiar chicken-breast, limiting the 
freedom of lung-action, thereby lessening the physiological func- 
tion of that structure and predisposing the child to grave lesions of 






PHARYNGEAL TONSIL. 463 

the lung. The profound anemia associated with this condition in 
grave cases is demonstrable by blood-examination, which shows 
marked interference with proper oxidation, with deleterious 
effect on the red corpuscles. The child may be round shouldered, 
ill-developed, and suffer from night-sweats, w T hich are the residt of 
labored breathing, increased on closing the mouth. It is restless, 
snores, and is troubled with night-terrors. When the adenoids are 
large they prevent proper closure of the soft palate, which allows 
regurgitation of food during deglutition. 

One of the early symptoms is the marked alteration in the 
character and tone of the voice, imparting to it a peculiar nasal 
twang, due to interference with nasal resonance. The enunciation 
and pronunciation, especially of consonants, is faulty, which 
may lead to stuttering; and stammering. Bv the lowered 
tone and the lessened physiological resistance of the nasal and 
pharyngeal mucous membrane, as well as the weakened vitality, 
susceptibility to infectious diseases is increased. Earache and 
deafness are among the prominent symptoms. These may be due 
to the enlargement of the adenoid structure impinging on the 
Eustachian orifice, or there may be gland-tissue lying within the 
tubal opening — the so-called tubal tonsil. This obstruction to 
the Eustachian tube interferes with the ventilation of the tym- 
panum and leads to Eustachian catarrh, catarrhal conditions of 
the middle ear, and, if infection occurs, may lead to chronic 
suppurative conditions, with involvement of the tympanum and 
possibly bony necrosis. In at least 90 per cent, of cases of ade- 
noid vegetation there is involvement of the Eustachian tube with 
deafness in a varying degree. 

There is no doubt, in some cases in which the deafness is only 
slight, followed by atrophy of the gland-structure, that the deaf- 
ness will entirely pass away ; but, as a rule, by the time atrophy 
takes place, permanent pathological alterations have been produced 
within the Eustachian tube and middle ear. 

Epistaxis, usually at night, may occur ; but, as a rule, the 
bleeding is very slight and is shown only by the blood-stained 
secretions. 

AVhen the vegetations are low down in the nasopharynx, with 
enlargement of the gland-structure behind the posterior pillars, 
the child will often complain of choking, when swallowing fluids. 

Enlargement of the faucial tonsil, relaxation of the soft palate, 
and elongation of the uvula are frequent concomitants of adenoid 
growths. The glands at the angle of the jaw are almost always 
enlarged. From the inability of the child to breathe through the 
nose there may be collapse of the nasal ala?, with atrophy of the 
nasal muscles, and owing to mouth-breathing the patient will 
suffer from dry mouth — xerostoma. There may also be a partial 
or complete loss of the sense of taste. The difficulty of breath- 



464 DISEASES OF THE TONSILS. 

ing is increased while eating, owing to the fact that the child is 
compelled to use the alimentary tract as a substitute for the re- 
spiratory tract. This will cause the swallowing of air with the 
food, and there will be eructation of gas after meals. Owing to 
the accumulated mucus in the nasopharynx and pharynx, together 
with the thickened gland-structure, the irritation produced will 
give rise to the constant desire to swallow. There is frontal head- 
ache, the eyes are dull, and the conjunctiva is frequently inflamed ; 
the sense of smell may be slightly affected, due to the congestion 
causing pressure on the terminal nerve-filaments. The symptoms 
given above will not all exist in any one given case, but will vary 
in intensity and in gravity, and depend in great measure on the 
location and size of the enlarged gland-elements. The shape of 
the nasopharynx also has much to do with the symptoms produced 
by glandular enlargement, as in some cases the cavity may be 
large enough to permit of marked distention without producing 
much obstruction to respiration. Indeed, considerable adenoid 
structure may exist in the central portion of the nasopharynx and 
produce no symptoms whatever. 

As the condition is often associated with various forms of rhi- 
nitis, there will also exist at the same time the symptoms peculiar 
to such form of inflammation. 

Diagnosis. — In early childhood one of the best points of 
diagnosis between adenoid vegetations and other obstructive lesions 
is the irregularity in the teeth ; this, together with the peculiar 
facial expression, the characteristic alteration in the voice, and the 
associated lesions of the ear, pharynx, and larynx, renders the 
diagnosis almost certain. Tumors of the nasopharynx rarely occur 
as early in life as adenoid vegetations. Rhinoscopic and digital 
examination will reveal the character and location of the structure. 

Prognosis. — If the condition is recognized early and prompt 
removal is accomplished, the prognosis is good. If, however, the 
gland-structure is allowed to remain until the bony framework is 
fixed, perfect nasal breathing may never be established. The 
effect on hearing depends upon the amount and continuance of the 
obstruction. 

Treatment. — Any impediment to the entrance of air through 
the upper or lower air-passages, especially in infancy and child- 
hood, gives rise to symptoms which call for quick recognition and 
demands early and prompt relief. In this one instance radicalism 
is less dangerous than inactivity. The successful treatment of 
enlarged gland-structure in the nasopharynx depends largely on 
its early recognition and prompt removal. This does not always 
demand operative interference, but in the majority of cases opera- 
tive measures to some extent will be necessary. The general con- 
dition of the patient should be looked into, and any existing 
constitutional diathesis corrected. In the cases in which the 



PHARYNGEAL TONSIL. 465 

enlargement is largely edematous and due to intestinal irritation, 
treatment directed to the intestinal tract will usually give prompt 
relief to the nasal obstruction. This is of necessity controlled by 
the existing symptoms in individual cases. 

The soft variety of adenoids will not demand the same ener- 
getic surgical interference which will be necessary in the hard 
variety. In the very young all that will be necessary is to lace- 
rate the soft gland-structure of the nasopharynx. In such cases 
thorough curetment is not necessary, for after scraping or lacerat- 
ing the gland-structure sufficient will absorb to give free nasal 
breathing. This will not require an anesthetic. Slight inflam- 
matory action will follow and absorption will take place. There 
is very little bleeding, with practically no pain. This operation 
should be done under measures as strictly antiseptic as possible. 
The nasopharynx should be carefully cleansed with a warm alka- 
line solution consisting of 8 grains of biborate and bicarbonate of 
soda to the ounce of water, followed by hydrogen peroxid and 
aqueous extract of hamamelis, in equal parts. 

One case observed in my clinic at the Jefferson Medical Col- 
lege Hospital, a child seven weeks old, with adenoids which evi- 
dently, from the symptoms, had existed since birth, revealed the 
gland-structure occluding the nasopharynx, the child being unable 
to feed without stopping at every act of swallowing to breathe 
through the mouth. The gland-structure was very soft, and easily 
crushed and removed with the finger. No anesthetic was given. 
In two days after the operation the child was breathing freely 
through the nose and able to feed naturally. 

As a rule, no after-treatment is necessary. If the secretions 
become mucopurulent after twenty-four to forty-eight hours, then 
cleansing sprays or douches should be used. This can be done by 
means of a postnasal syringe, with a boric-acid solution, 8 gr. 
to the ounce. This should be continued as long as the secre- 
tions are blood-stained. If there is much irritation after the 
cleansing there should be applied every other day to the sur- 
face, by means of a curved applicator, a solution of the tincture of 
benzoin and 50 per cent, boroglycerid, equal parts. However, 
usually, no after-treatment is necessary. 

Equally good for local application is the benzoate-of-soda 
solution, 10 gr. to the ounce, or 3 per cent, chlorid of zinc. 
From its good effects elsewhere I would suggest the application 
of glycerinated extract of suprarenal capsule or adrenalin chlorid. 
If the tissue is very sensitive good results can be obtained by the 
local application of a -^ of 1 per cent, formaldehyd in 4 per cent, 
cocain. Good astringent effects may be obtained by applying a 
solution containing 8 grains of alum and 4 grains of tannic acid 
to the ounce of water. 

The existing conditions may be such as to demand immediate 

30 



466 DISEASES OF THE TONSILS. 

radical surgical interference — as the procedure given above applies 
only to the very soft variety, in the very young. 

In the removal of the pharyngeal tonsil it must be remembered 
that it is not a new growth in the nature of a neoplasm, but simply 
an enlargement of a physiological structure, and that the ablation of 
such gland-structure is demanded only when it is interfering with 
nasal respiration, when its presence is deleterious to the child's 
health, or when it produces lesions of associated structures. 

Anesthesia. — Operative interference raises the question of 
anesthesia. In children it is better to give a general anesthetic 
than to use a local one. The selection of the anesthetic is deter- 
mined by the condition of the individual and the extent of the 
surgical interference. There is less shock, too, from the operation 
when anesthesia is employed ; besides, the case can be observed 
longer after operation — especially clinic cases — and often complica- 
tions after operation can be averted. Where profound narcosis is 
not necessary the nitrous oxid and oxygen gas, after the method 
of Casselberry, is quite sufficient. Where the operation is likely 
to occupy more time, and where it may be necessary to remove 
a portion of the faucial tonsil, ether should be employed. Per- 
sonally I prefer chloroform with oxygen, and when administered 
by a competent anesthetizer, I think it is as safe an anesthetic 
as can be employed ; besides, it is rapid in its effect and the 
after-effects are not so bad as in the case of ether. Neither 
nitrous oxid nor chloroform produces so much turgescence of the 
mucous membrane as ether. In surgical work involving the 
upper respiratory tract the administering of the anesthetic is of 
the greatest importance, and it requires a skillful and experienced 
anesthetizer ; and after all has been said pro and con as to the dan- 
gers of the various anesthetics and advantages of the one over 
the other, the best anesthetic is a good anesthetizer. Some operators 
prefer to remove the pharyngeal adenoid growth without giving a 
general anesthetic. This certainly can be done under local anes- 
thesia in adults, but I think in children the shock of the opera- 
tion is certainly very grave and is attended with as much risk as 
to give an anesthetic. Under complete anesthesia the patient 
is under perfect control and there is no spasmodic contraction 
or reflex action of the tissues of the pharynx, thus rendering the 
field of operation easily explored and lessening the danger of fail- 
ing to remove all the gland-tissue from the nasopharynx. 

Ether is, in the vast majority of cases, a perfectly safe anesthetic. 
Where there is nasal obstruction due to the adenoid growth, and 
also pharyngeal irritation caused by the necessitated mouth- 
breathing, the patient's mucous membrane is irritable, and under 
the stimulation of the anesthetic quantities of mucus are poured 
out. I have found that the addition of a few drops of oil of Hun- 
garian pine to the ether, as suggested by Rover, will in a great 



PHARYNGEAL TONSIL. 467 

measure lessen this flow of mucus and prevent considerably the 
irritation. 

There is no question that in children having large masses 
of adenoid tissue the general condition is usually below par ; that 
their breathing is shallow ; that they do not receive the proper 
amount of oxygen ; and that they are bad subjects for anesthesia, 
so that in these adenoid cases the risk of giving an anesthetic is 
much greater than in many other surgical conditions. 

While it takes considerably more time, I believe that the anes- 
thetic should be given very slowly in these cases. In the author's 
operative work Dr. Thomas C. Stellwagen, who is a skilled 
anesthetizer, pursues this method Avith most excellent results. 
There is less shock afterward and the patient reacts very quickly. 
I also believe that it is much safer to have the patient completely 
anesthetized while operating on the nasopharynx or on the pharyn- 
geal structures. The parts are free from all spasm when the 
patient is thoroughly relaxed. 

The other points of importance are these : First, having the 
patient at rest and in bed the day before giving an anesthetic. 
Second, operating in the morning, the patient having had nothing 
to eat since the previous evening. 

Careful attention should be given to the intestinal tract and 
thorough purgation should be enforced the day before the opera- 
tion. Great care should be exercised in sponging the throat in 
attempts to remove the mucus before the patient is completely 
anesthetized, as the irritation of the still sensitive pharyngeal 
surface will often produce retching and vomiting. 

If the patient becomes cyanosed during anesthesia and the 
abdominal muscles are rigid and spasmodic, there is no cause for 
alarm, as the cause of the cyanosis will be due to the fact that the 
patient is nauseated and holding his breath, and on the point of 
vomiting. If, however, the patient is cyanosed and the abdominal 
muscles are relaxed and flabby, it is usually a danger signal, and 
you will find that either the respiratory or cardiac centers are failing 
to act. 

Occasionally during anesthesia, where there is some difficulty 
in respiration, it has been found that on drawing the tongue 
upward and forward, which is the usual method of freeing the 
epiglottis, instead of adding to the patient's comfort and reliev- 
ing the obstruction to breathing, it has increased it. It has been 
my privilege to see several such cases. On examination it was 
found that the anterior portion of the axis and atlas, and in 
another instance the second vertebra — the anterior portion extended 
forward, in other words — was so enlarged that it produced an 
offset in the pharynx at such a point that when the tongue was 
drawn forward and the larynx elevated it pressed the epiglottis 
against this protruding pharyngeal wall, showing that in all cases 



468 DISEASES OF THE TONSILS. 

the method of drawing the tongue forward and upward is not ap- 
plicable. 

The most convenient mouth-gag for use in operations about the 
pharynx is shown in Fig. 178. It is easily retained, not in the 
way, and can in no wise injure the teeth. 



Fig. 178.— Stubb's mouth-gag. 

The rectal method of administering ether, as suggested by 
Cunningham and Stucky, certainly would be of great advantage 
in certain major operations about the larynx and trachea. The 
technic of the method, however, requires so much previous prep- 
aration and the administration of the anesthetic is too tedious to 
be of practical value for minor operations. Stucky, in his reports 
of cases, believes this method of giving anesthetics to be a very 
safe one. 

The giving of an anesthetic in throat and nose work is espe- 
cially difficult, owing to the fact that the duties of the anesthetizer 
are interrupted and interfered with by the operator, and it is 
difficult for the anesthetizer to perfectly control his anesthetic after 
the operation is begun. The patient is likely to partially recover 
from the effects of the anesthesia, and, owing to this interruption, 
it is difficult for the anesthetizer to keep his patient just at the 
point of complete anesthesia. 

When the patient is completely under the influence of the 
anesthetic he should be placed on the table in such a position 
as to allow the head to drop over the edge, or if an operating 
table is used he should be placed in a modified Trendelenburg 
position. If in this position there is a tendency to turgescence of 
the veins and continued bleeding the patient should be quickly 
raised into an almost sitting posture for a half minute, the 
Trendelenburg position discontinued, and the table adjusted to 
the perfectly flat position. By inserting the mouth-gag, drawing 



PHARYNGEAL TONSIL. 



469 



the tongue forward, and elevating the uvula, a part of the naso- 
pharynx will be exposed, giving a fair view of the field of opera- 




Fig. 179— Gottstein's adenoid curet. 



tion. A modified Gottstein curet (Fig. 179) or Richard's modi- 
fication of Schultz's adenotome (see Fig. 180) should be used. 




Fig. 180.— Richards' modification of Schultz's adenotome. 

The blade is not so large as the original instrument ; the curved 
portion is a little longer and the curve more pronounced. In some 
cases the adenoid structure is small in amount, but located high 
up in the vault of the nasopharynx, thereby causing marked ob- 
struction. In such cases the curet, shown in Fig. 181, should be 



^ 



Fig. 181.— Author's adenoid curet to be used through the nose. 

used. It can be passed through the nose, and the finger passed 
into the nasopharynx will guide the iDstrument. This is also true 
when the large mass of adenoid structure has been removed from the 
nasopharynx ; there is still a small amount located high up in the 
vault, almost in the choanal. This cannot be reached by the post- 
nasal curet. In such cases the author's curet, shown in Fig. 181, 
should be used to remove the portion of the gland that lies almost 
within the nasal cavity. This instrument is not intended for the 
removal of the entire adenoid growth, but for such conditions as 
above stated. Since the field of operation cannot be even partially 
exposed, the Gottstein curet should be guided with the index finger, 
care being taken not to lacerate the structures around the Eustachian 
orifice. Following the operation I leave the patient perfectly at 
rest, avoiding the use of douches unless after twenty-four to forty- 
eight hours a mucopurulent discharge should occur. 

If there is enlargement of the faucial tonsil to such an extent 
as to demand removal, this should be done before the removal 
of the adenoids. There is very little danger from hemorrhage in 



470 DISEASES OF THE TONSILS. 

either case, unless from an anomalous vessel. If marked bleed- 
ing should occur from the nasopharynx, it can usually be controlled 
by compressing into the nasopharynx a large pledget of gauze 
and exerting pressure for a few minutes. The patient should be 
watched carefully for the first six hours, for any secondary hem- 
orrhage. The nurse should be instructed to waken the patient 
every half hour, so as to observe whether any bleeding has 
occurred or is occurring. Should secondary hemorrhage take 
place and be of an alarming character, the postnasal space should 
be packed with gauze. Healing usually takes place rapidly, the 
only cases in which it is delayed being those of strumous or 
tubercular tendency, which are more likely to become infected and 
lead to ulcerative processes. 

In adults the adenoid structure is likely to be more fibrous, 
firm, and dense. In such cases the biting-forceps, shown in Fig. 




Fig. 182 — McAuliffe's adenotome. 

182, should be used. The removal of the gland in such cases 
can be done either under local or general anesthesia. 

Some cases have been reported in which spasmodic torticollis 
followed the operation of adenotomy. The spasmodic torticollis 
was evidently reflex or it is barely possible that it was a mere 
coincidence, as all cases reported have been in nervous children. 

FAUCIAL TONSIL. 

Inflammatory Diseases. 

a. Acute : 

1. Systemic Infection through the Tonsils. 

Tubercular. 

Specific. 

Streptococcal. 

2. Acute Superficial Tonsillitis. 

3. Cryptic Tonsillitis. 

4. Rheumatic or Gouty Tonsillitis. 

5. Diabetic Tonsillitis. 

6. Herpetic Tonsillitis. 

7. Tonsillar and Peritonsillar Abscess. 

8. Membranous Inflammation of the Tonsil. 



ACUTE SUPERFICIAL TONSILLITIS. 471 

6. Chronic : 

1. Enlargement or Hypertrophy of the Tonsil. 

Surgical Tonsil. 

2. Submerged or Embedded Tonsils. 

3. Caseous Tonsillitis. 

4. Chronic Abscess of the Tonsil. 

5. Atrophy of the Tonsil. 

6. Gangrene of the Tonsil. 

7. Mycosis of the Tonsil. 

8. Actinomycosis of the Tonsil. 

c. Foreign Bodies in the Tonsils. 

The faucial tonsil is, in reality, a large lymphatic gland. From 
its intimate vascular and lymphatic connection with tissue and its 
exposed position it is an important structure from a pathological 
standpoint, as it is the site not only of local pathological changes, 
but also of pathological alterations which may be local manifesta- 
tions of a constitutional condition. Again, the tonsillar structure, 
when subjected to superficial ulceration, may form a channel for 
systemic infection. The local primary infection may be associated 
with involvement of other pharyngeal and laryngeal structures, 
as is observed in the eruptive fevers, diphtheria, scarlet fever, 
small-pox, and measles. Irritating materials in the blood may 
also be an exciting factor. This is especially true in the 
rheumatic and gouty diatheses, or in any form of intestinal 
obstruction in which there is absorption of toxic material into the 
systemic circulation. In all forms of anemia there is a tendency to 
pathological alteration in the lymphoid structure of the tonsil. The 
inflammatory process may be limited to merely the mucous membrane 
covering the tonsil, or secondarily extend over adjacent structures. 
This is known as acute superficial or catarrhal tonsillitis. In reality, 
many of the different varieties of inflammation of the tonsil differ 
only in degree and cause, the severity of the attack determining the 
pathological alteration. When the inflammation involves the crypts 
or lacunae, it is known as cryptic (lacunar) tonsillitis. If the whole 
gland-structure of the tonsil is involved, it is known as parenchy- 
matous tonsillitis. Occasionally the lacunar variety may go on to 
ulceration, and is known then as ulcerative lacunar tonsillitis. 
However, in any form of inflammation involving the tonsil, ulcer- 
ation may occur. This is true whether it be due to a gouty or a 
uric-acid diathesis, whether it be associated with an infectious proc- 
ess or due to inflammation extending from adjacent structure. 

ACUTE SUPERFICIAL TONSILLITIS. 

Definition. — An acute inflammatory process involving the 
mucous membrane covering the tonsil, which may also involve the 
crypts and deeper structure, and either spread through or be caused 
by inflammation of adjacent structures. 



472 DISEASES OF THE TONSILS. 

Synonyms.— Acute catarrhal tonsillitis; Tonsillitis; Acute 
catarrhal angina. 

Etiology. — Acute inflammation involving the mucous-mem- 
brane lining of the tonsil is most common in children and young 
adults. This may be explained by the fact that the lymphoid 
structure is at its full development at this age, and with increased 
years undergoes atrophy, with a lessened likelihood of inflamma- 
tion. Many cases of the acute angina are due to exposure to cold 
or sudden thermic changes. They also may be brought about by 
injury, either direct to the tonsil or of adjacent structure. Direct 
irritation may be mechanical, or may be the result of irritating 
fumes, vapors, scalds, or inhalation of steam. Irregularities in 
the respiratory tract causing mouth-breathing may also predispose. 
Systemic involvement, with lowered vascular tone, is also an 
important predisposing factor. Gastro-intestinal involvement 
through venous stasis may predispose to acute tonsillitis. The 
simple variety may predispose to a more serious affection, as the 
secretion and inflammatory exudate which collects in the crypts 
will form a suitable nidus for bacteritic infection. Secondarily 
the deeper structure may be involved, and superficial tonsillitis 
become a parenchymatous one. 

Pathology. — The pathology is that of a catarrhal inflamma- 
tion of any mucous-membrane surface. The inflammatory process 
may undergo resolution and return to the normal, or the secondary 
infection may entirely alter the variety of inflammation and be 
followed by superficial necrosis (ulceration). 

Symptoms. — The symptoms vary much in severity. There 
are usually a feeling of malaise, slight headache, stiffness in the 
muscles of the neck, a slight chill followed by fever. At first 
there is slight pain on swallowing, with the sensation of a swell- 
ing; and, as the case progresses, the pain may be continuous, 
although aggravated by deglutition. As the case grows worse, 
movements of the head and neck become painful, and there may 
be actual torticollis. The surface of the tonsil is deep red in color, 
and slightly edematous-looking ; the surrounding structures, espe- 
cially the palate and uvula, are similarly involved. As the inflam- 
matory exudate increases, the crypts will become filled with serum 
and fibrin resembling patches of membrane. There may be reflected 
pain in the ear, and by the vascular alteration there may be tin- 
nitus on the affected side. Owing to the alteration in the vas- 
cular supply about the epiglottis and vestibule of the larynx, there 
will be marked alteration in the voice. The voice may also be 
altered owing to interference with nasal resonance from the involve- 
ment of the uvula and soft palate. In children the symptoms 
may be much more aggravated and the onset more sudden. There 
is a marked tendency to recurrence, and the repeated attacks will 



ACUTE SUPERFICIAL* TONSILLITIS. 473 

cause marked permanent enlargement^ the tonsil. In this super- 
ficial variety there is rarely any glandular involvement. 

Diagnosis. — In this variety both tonsils are frequently 
involved. The rapid course of the disease, the associated clinical 
phenomena, and the absence of the adherent membrane, either on 
the tonsil or adjacent structure, will aid materially in the diagnosis. 

Prognosis. — The prognosis is good as regards recovery from 
the immediate attack, but there is great likelihood of recurrence. 

Complications. — Occasionally, after the acute phenomena 
have passed away, there may be relaxation of the vocal bands, 
caused by congestion about their base. This loss of voice may come 
on when all soreness in the tonsil has disappeared. Occasionally 
there may be catarrhal or purulent otitis media. There may be 
elongation of the uvula, due to relaxation of the soft palate. 

Treatment. — If the patient is seen early in the attack, much 
can be done toward shortening the attack and lessening its sever- 
ity. There should be administered at once a purgative — calomel, 
grain -J-, and sodium bicarbonate, grain 1 — every hour for six doses, 
followed by a saline such as a Seidlitz powder, and the tonsils should 
be carefully touched with pure guaiacol. This should be not only 
on the outer surface, but the crypts should be mopped as well. 
The application should be made by means of cotton tightly wrap- 
ped on a probe, being careful to remove the excess of guaiacol 
before applying to the membrane, so as to prevent the solution 
running over the surrounding structures. This procedure should 
be repeated not oftener than every third hour for three applica- 
tions. Usually three applications suffice to abort the attack. If 
not effectual after the third application, the use of the guaiacol 
should be discontinued. At the same time there should be given 
internally from 15- to 20-drop doses of ammoniated tincture of 
guaiac in wine or milk — each dose at an interval of two hours. 
Instead of the internal administration of the guaiac there may be 
used 15 to 30 drops of tincture of chlorid of iron every three 
hours, or a capsule containing bromid of quinine 2 grains, extract 
of belladonna \ grain, and salol 3 grains, one capsule every three 
hours. If, from the character of the onset and symptoms, a severe 
attack is anticipated, the patient should be put to bed and a 5- to 10- 
grain Dover's or 5-grain Tully's powder administered. To relieve 
the tonsil of the accumulated material on the surface and within 
the crypts, a gargle of equal parts (1 ounce) of hydrogen peroxid, 
aqueous extract of hamamelis, and cinnamon Avater, with 10 grains 
of chloral hydrate, should be used every hour. In the early stage 
the application of cold externally will aid materially in aborting 
the attack. The patient should also be instructed to gargle the 
throat frequently with ice water. This, however, should only be 
employed early in the attack — really at the onset. For the relief 



474 DISEASES OF THE TONSILS. 

of the pain and to allay the congestion, a local application of j 1 -^ 
of 1 per cent, of formaldehyd in 4 per cent, of cocain should be 
employed. Should the inflammatory process involve the deeper 
structure and become more parenchymatous, the tonsil swollen 
and tense, with marked difficulty in swallowing, there should be 
added to the local treatment free bleeding by multiple punctures, 
preferably by means of a sharp-pointed probe, as the puncture can 
be controlled, and there is no danger of making too deep or free 
an incision or of wounding the surrounding structures by the sud- 
den movements of the patient. At this stage hot applications 
should be employed externally and internally. The throat should 
be frequently gargled with water as hot as can be comfortably 
borne by the patient, and hot applications, in the form of a hot- 
water bag, should be applied externally. 



CRYPTIC TONSILLITIS. 

Synonyms. — Lacunar tonsillitis ; Follicular tonsillitis. 

This variety of inflammation of the tonsil differs very little 
from the superficial variety, the main point of difference being 
the extent of the structures involved. There may be a few of the 
crypts, or the entire tonsil may be involved in the process. If the 
inflammation extends into the deeper structures and involves the 
entire tonsillar tissue, it is known as parenchymatous tonsillitis. 
The variety of inflammation is controlled more by the tissue-alter- 
ation and the structures involved than the cause. 

Etiology. — The susceptibility to this variety of tonsillitis is 
largely increased by the anatomical structure of the tonsil. The 
deep-seated crypts (Fig. 183) with small orifices tend to the 
accumulation of material which may not be to the extent seen in 
the caseous variety, but of sufficient amount to produce irrita- 
tion within the crypts of the tonsil and, owing to this accumula- 
tion of decomposing material, a suitable nidus is formed for 
bacterial infection. The general systemic condition of the indi- 
vidual, whether he be of the tubercular or strumous diathesis, or 
weakened by any constitutional disease, with lessened physiological 
resistance, is also a predisposing cause. Exposure to cold, or to 
climatic and thermic changes, is a predisposing factor. As the 
diseased process begins within the tonsillar crypts, it chiefly attacks 
persons from ten to thirty years of age. 

Pathology. — The enlargement of the tonsil is due to engorged 
vascular supply, accumulated secretion, and inflammatory exudate 
within the tonsillar crypts, as well as by the inflammatory exu- 
date into the parenchymatous structures. This consists in a 
serous exudate, which accounts for the edematous condition of the 
gland as well as the infiltration of the migrated leukocytes. The 



CRYPTIC TONSILLITIS. 475 

inflammatory exudate poured out on the surface as liquor san- 
guinis separates as serum and fibrin. Much of the fibrin may be 
deposited in the crypts and give rise to a false membrane, or rather 
give rise to the false impression that a membrane is formed, as it is 
merely the retained inflammatory exudate. From infection through 
the crypts and from the cutting off of the blood-supply to the 
inflamed area of the tonsil, the tissue may undergo liquefaction- 
necrosis and abscess-formation, as described under Tonsillar 
Abscess (page 482). 

Symptoms. — Pain is a constant, ever-present symptom ; it is 
increased on motion, especially on opening the mouth or by the 



Fig. 183.— Enlarged faucial tonsils ; the left tonsil shows a large crypt. 

act of deglutition. There is pain reflected to the ear and in the 
cervical region. The phonetic quality of the voice will be 
impaired. Respiration is rarely ever impeded, as far as free pas- 
sage of the air to the lungs is concerned, although when inflamma- 
tory swelling not only of the tonsil but of the postpharyngeal 
structure is present, nasal respiration may be impaired or entirely 
obstructed. There may be considerable irritating cough, due to 
the reflex action, owing to involvement by inflammatory pressure 
of the phrenic and recurrent laryngeal nerves. There is a con- 
stant desire to clear the throat. As a rule, only one tonsil is 
involved, but occasionally both may be inflamed at the same time. 
The increased pain on deglutition is due to the narrowing of the 
faucial orifice and to muscular spasm. The pain, which is of a 
lancinating character, seems located more in the temporomaxillary 
articulation. Owing to the swelling and pain on motion, it may 



476 DISEASES OF THE TONSILS. 

be almost impossible for the patient to swallow solids or even 
liquids, the reflex spasm being so marked as to cause regurgitation 
of the fluid or food through the nostrils. 

There may be extension of the inflammation into the naso- 
pharynx, involving the Eustachian orifice and tube, thereby giv- 
ing rise to pain in the middle ear. The inflammatory process 
may extend and produce a catarrhal otitis media. Inspection 
of the tonsil is sometimes quite difficult, owing to the inability of 
the individual to open his mouth. If seen, the tonsillar surface 
will present an edematous, deeply reddened appearance, with here 
and there the whitish or yellowish points showing the orifice of 
the crypts. If the inflammatory exudate has been profuse, there 
will be oozing over the surface a serofibrinous material resembling 
somewhat a membranous inflammation. The febrile symptoms 
vary, depending entirely upon the degree of the inflammatory proc- 
ess and the associated infection. There is, however, usually a 
considerable rise of temperature, the skin is warm and dry, and 
the patient is nauseated. As the condition advances with threat- 
ened suppuration, the patient will be cold and clammy, with slight 
chills^ marked facial pallor, mental depression, and with a 
peculiarly anxious expression of the countenance. The tongue is 
coated, the breath foul. Thirst is constant. The marked clinical 
phenomenon which accompanies all inflammatory processes — that of 
perverted secretion — is quite marked in this variety of tonsillitis. 
There is obstinate constipation ; the urine is scanty in amount, 
high-colored, contains an excess of urea and urates, and often a 
marked amount of indican, with usually a deficiency in the amount 
of chlorids. If associated with any marked uric-acid diathesis, 
or if cold and exposure have been the exciting factors, with a 
sudden onset and rapid rise of temperature, quite frequently a 
small amount of albumin may be found in the urine. The glands 
at the angle of the jaw may be involved, but, if so, are not impli- 
cated early. Frequently in children will be observed a tonsil 
which is not markedly enlarged. However, the child has fre- 
quent attacks of a mild form of tonsillitis. The general history, 
which is usually obtained from the family physician, is that the 
child is a little below par, has repeated and frequent attacks of sud- 
den rise in temperature which will last from one to three days and 
then resume the normal ; that the child is irritable and frequently 
complains of feeling tired. Blood-examination shows a slight 
anemia and no definite set of symptoms can be outlined. There is 
usually a certain amount of enlargement of the glands of the 
neck following the chain of anterior cervical lymphatics. While 
the tonsil is not so large apparently, yet it is partially submerged 
and adherent to the anterior and posterior pillar of the fauces. I 
have observed a number of such cases, and when the tonsil was 



CRYPTIC TONSILLITIS. 477 

freed thoroughly from the pillars by means of the tenaculum-forceps 
and the tonsil drawn out with its capsule (see Fig. 190), there has 
been found imbedded back of the tonsil a mass of caseous material, 
broken-down epithelium, and extraneous matter which had filtered 
in through the crypts of the tonsil. From this condition the child 
was constantly absorbing into the circulation poisonous material. 
In such cases the tonsils should be freely dissected and then re- 
moved by means of the Farlow punch, as seen in Fig. 194, and 
all caseous material carefully scraped out. The adherent pillar, 
after having been resected from the tonsil, frequently presents 
a very ragged and jagged appearance. Nothing should be done 
for this but simply allow the tissue to retract, and usually in from 
ten days to three weeks the pillar will have almost resumed its 
normal shape and position. It is a mistake to attempt to trim off 
any of this ragged material, as it is somewhat fibrous and inflam- 
matory, and, after haviug been freed from the tonsil, owing to the 
now perfect muscular action and normal circulatory and lymphatic 
supply, the tissue rapidly responds and resumes the normal. 

Diagnosis. — The question of the presence of the Klebs- 
Loffler bacillus can be determined by a microscopical examina- 
tion, and the severity of the symptoms, together with the macro- 
scopical appearance of the tonsil, will differentiate it from the 
superficial variety. The caseous variety is more chronic in char- 
acter and does not have the accompanying clinical phenomena ; 
besides, as a rule, individual crypts show only the inflammatory 
process. 

Prognosis. — The prognosis is favorable, and, if the condition 
is properly treated and is seen sufficiently early in the inflamma- 
tory process, it rarely, if ever, goes on to suppuration. 

Treatment. — Attention should at once be given to the pro- 
moting of secretions. The early treatment is the same as given 
under Acute Superficial Tonsillitis. A capsule containing — 

I$*. Quininse bromidi, gr. ij (.12); 

Antipy rinse, gr. iij (.18) 

should be administered every three hours until the fever is les- 
sened. Early in the case internal and external application of cold 
is of great benefit, in the form of ice packs externally, and inter- 
nally in the form of ice-water sprays and gargles or cracked ice in 
the mouth. Frequently the inflammatory process can be aborted 
by applying first a local anesthetic, such as a 6 per cent, to 8 per 
cent, cocain solution, and then by means of a blunt probe-curet 
open the individual crypts and remove as much as possible of the 
accumulated material. The tonsil should then be thoroughly 
mopped with hydrogen peroxid and cinnamon water, in equal 



478 DISEASES OF THE TONSILS. 

parts, and the entire surface touched over with pure guaiacol. I 
believe in many cases this will effect prompt relief. Should the 
examination of the urine show any uric-acid diathesis, the internal 
administration of salicylates should at once be instituted, prefer- 
ably in the form of the salicylate of sodium, in 10-grain doses 
every three hours, or a capsule containing — 

1^. Sodii benzoatis, 
Salol, 

Phenacetini, da gr. iij (.18) 

given every three hours. Should the process be far advanced before 
treatment is begun, the crypts should be punctured at once, the 
tonsils scarified, and the treatment as given above instituted. 

RHEUMATIC OR GOUTY TONSILLITIS. 

In any condition in which irritating material is present in the 
blood, whether associated with infectious processes in the form of 
toxins, owing to absorption of toxic material from the intestinal 
tract, or to an excess of uric acid in any of its peculiar forms, the 
lymphatic structure is likely to be involved. This is especially 
true of the faucial tonsil. The variety of inflammation of the tonsil 
which is due to such causes is not a special one. It may be a 
superficial tonsillitis or a cryptic, or the so-called parenchymatous, 
involving the entire structure. It is most likely to occur in 
individuals of the lymphatic temperament and of a strumous 
diathesis. There is a history of repeated attacks of acute tonsil- 
litis, varying in severity and degree. The attacks may be accom- 
panied with slight constitutional symptoms of uric-acid or rheu- 
matic conditions, or there may be no systemic manifestations 
whatever. While there are acute exacerbations, yet the irritation 
is constant, and the inflammatory process, although lacking in clin- 
ical phenomena, goes slowly on. The tonsils are large, irregular, and 
may almost fill the faucial space. This enlargement, of course, inter- 
feres with function and nasal resonance. The thick, muffled voice, 
the constant accumulation of secretion in the throat, foul breath, 
usually due to the accumulated material in the crypts of the tonsil, 
and the regurgitation into the nasopharynx of food and fluid on 
attempts to swallow are present. The uric-acid diathesis may exist 
early in life — indeed, I believe much earlier than is generally sup- 
posed. Quite frequently, in children, it is very difficult to secure 
a sample of urine for examination ; but in many cases of enlarged 
tonsils, with a history of repeated attacks of tonsillitis in children six 
to ten years of age, on examining the urine uric acid has been 
found in excess. Yet the finding of uric acid in the urine does 
not always mean that there is an accumulation of uric acid in the 
blood, since the powers of elimination may have been increased 



RHEUMATIC OR GOUTY TONSILLITIS. 479 

and stimulated, and the excess which brought on the attack is 
being properly eliminated. Frequently, previous to the attack, if 
the urine is examined, there will be found a deficiency of uric acid, 
which predisposes to the attack. There is the stirring up of the 
uric acid within the system in addition to the failure of elimination, 
so that the urinary examination might be misleading, and, when 
the excess of uric acid appears, instead of being a grave symptom, 
it shows to the clinician that the normal functions are endeavoring 
to take care of and eliminate the uric acid. Frequently, before 
the acute attack which is due to this uric-acid diathesis, the patient 
will suffer from general malaise, dull headache, listlessness, pain in 
the joints and in the back, stiffness in the neck, with a slight sore- 
ness of the throat. The mucous-membrane surfaces are generally 
irritated. There may be associated diarrhea or there may be an 
excessive flow of urine, although the flow is frequently diminished. 
As far as the actual phenomenon in itself is concerned, the patho- 
logical change is practically that of any other variety of acute ton- 
sillitis ; indeed, the different varieties are more dependent upon the 
cause than the actual pathological alteration. With the repeated 
attacks there is likely to be increase of the connective-tissue ele- 
ment of the tonsil, and the enlarged tonsil will be of the hard 
variety (Fig. 186), although the glandular structure will also be 
increased, but not to the extent that it is in the soft variety (Fig. 
185). m 

Diagnosis. — The diagnosis cannot be made from clinical 
observation — that is, from the simple local inflammatory process 
— but must be determined by a careful clinical study of the general 
condition of the patient, whether he be child or adult. The history 
of repeated attacks, the family history of rheumatic or gouty 
diathesis, and last, but most important, the urine examination, will 
clear up the diagnosis. 

Prognosis. — The prognosis is favorable, and depends entirely 
upon the correction of the uric-acid diathesis. 

Treatment. — The local treatment is directed to the relief of 
the pain and the predominating symptoms causing inconvenience 
to the patient, but for the permanent cure of the condition medica- 
tion must be directed toward the constitutional diathesis. Exercise 
to the point of fatigue should be insisted upon. Great attention 
has been given to the diet, but when we eliminate from the diet all 
the materials that may tend to form uric acid, it leaves very little 
for the nourishment of the individual, and I think more atten- 
tion should be given to the stimulation of the eliminating and 
secretory organs and to outdoor exercise to the point of actual 
fatigue. Careful attention should be given to the intestinal 
tract, relieving any tendency to constipation. For this pur- 
pose nothing is better than the granular effervescing phosphate 
of soda in tablespoonful doses in a glass of cold water, one to 



480 DISEASES OF THE TONSILS. 

three times a day, preferably given the first thing in the morning 
and on retiring. When the individual's habits are rather seden- 
tary, a pill of resin of podophyllum, J grain taken before each meal, 
the repetition of the dose controlled entirely by the tendency to 
constipation, if continued for a considerable time will correct the 
intestinal sluggishness. For the stimulation of glandular secretion 
and its effect on systemic and intestinal digestion, there should be 
administered dilute hydrochloric acid, from 6 to 10 drops in 
water, instructing the patient to take it through a glass tube. This 
should be taken after each meal. During the acute attack a 
capsule containing — 

1^. Salol, gr. iiss (.15); 

Sodii benzoinatis, 

Phenacetini, ad gr. iij (.18) ; 
Strychnine nitratis, gr. -fa (.0015) 

should be given every four hours. The selection of the drugs to 
be administered must be determined by the clinician, and is 
entirely dependent upon the severity of the attack and the sys- 
temic effect of the uric-acid diathesis. In some chronic cases 
better results will be obtained by pushing the alkalies. The 
benzoate of sodium or the bicarbonate of lithium, 5- to 10-grain 
doses every three hours, will be most beneficial. In some cases 
better results may be obtained by the administration of alkalies, 
alternating in ten days with the dilute hydrochloric acid. Warm 
baths or Turkish baths taken twice a week are beneficial in pro- 
moting skin-elimination. However, the patient's general condi- 
tion may be such as not to permit of so frequent use of the warm 
baths. This is often the case, as in the uric-acid and rheumatic 
diatheses there is very likely to be heart-complications, and the 
depressing systemic effect of the hot bath will do more harm than 
the stimulation of secretion will do good. 

HERPETIC TONSILLITIS. 

This is a condition in which there form on the tonsil numerous 
herpetic vesicles which are associated with an acute inflammation 
of the pharynx, accompanied by considerable systemic disturb- 
ance. 

Etiology. — The condition seems to be associated with 
some constitutional diathesis, general lowered vitality, or the 
various forms of anemia, especially that due to malaria. The 
exciting cause is usually cold or exposure. In some instances 
the condition seems to point almost to contagion, several cases 
appearing in the same house ; bacteriological examination, how- 
ever, gives contradictory results. It seems to be rather a local 



HERPETIC TONSILLITIS. 481 

condition, which may be brought about by a number of causes, 
and although many bacteria, especially the staphylococci and 
streptococci are found, they are not, however, direct etiological 
factors. In some instances the Klebs-Loffler bacillus has been 
found. 

Pathology. — The minute vesicle which forms resembles 
somewhat a bleb, the contents being fluid or semi-fluid. The 
outer wall of the .vesicle is a thin layer of mucous membrane, on 
the surface of which may be formed some false membrane, which 
is due to a coagulative necrosis in the surface-epithelium, as well 
as a fibrinous exudate from the blood-vessels. 

Symptoms. — The onset is rapid, the temperature is usually 
high, with decided chills, aching pains in the bones, anorexia, 
intense headache, thickly coated tongue, and decided nausea ; the 
pharynx and tonsils present a decidedly red appearance and 
are painful. The minute vesicles repeatedly appear on the 
pharyngeal and tonsillar surfaces, first as separate and distinct, 
but on the second day may run together and form large blebs. 
The lesion will usually rupture within twenty-four to forty-eight 
hours and leave a minute, whitish ulcer. As a rule, there is no 
glandular involvement. The condition usually lasts from three 
to four days, disappearing and leaving no traces whatever of the 
ulcers. 

Diagnosis. — The diagnosis can be determined by bacterio- 
logical examination, although the presence of the Klebs-Loffler 
bacillus would not determine the condition to be diphtheria, as 
the bacillus of diphtheria may exist in the buccal cavities of 
healthy individuals. It will be necessary, then, to take into 
account the clinical facts with the history of the case ; indeed, 
this should always be associated with any bacteriological exami- 
nation. 

Prognosis. — The prognosis is good, although there is a ten- 
dency to repeated attacks. 

Treatment. — The patient's general health should be improved 
and any existing constitutional diathesis corrected. For the 
immediate relief of the attack, the local application two or three 
times daily of compound tincture of benzoin and 50 per cent, boro- 
glycerid, in equal parts, will give comfort ; or a warm gargle of 
10 grains of chloral hydrate with 1 dram of glycerin to the ounce 
of water will afford relief to the burning sensation and local pain. 
There should be administered small doses of calomel, -^ grain, and 
1 grain of bicarbonate of soda every hour for eight or ten doses, 
followed by Rochelle salts to the point of free purgation. For the 
relief of the headache and fever a capsule containing — 

1^. QuininaB bromidi, 

Phenacetini, da gr. iij (.18) ; 

Salol, " gr. iiss (.15) 



482 DISEASES OF THE TONSILS. 

should be given every three hours until the desired effect is 
obtained. 



TONSILLAR AND PERITONSILLAR ABSCESS. 

Synonyms. — Peritonsillar phlegmon ; Phlegmonous tonsil- 
litis ; Quinsy ; Circumtonsillar abscess. 

A suppurative inflammation that is limited to the tonsillar 
structure is a rare condition. As a rule, the suppurative process 
is in the peritonsillar tissue. The condition may be brought about 
by an infection through the tonsil from without, either following 
superficial ulceration or associated with some membranous or in- 
flammatory process of the tonsil and surrounding structure. How- 
ever, the abscess-formation is often associated with a systemic 
septic process, or may be due to infected emboli. Peritonsillar 
abscess is not uncommonly associated with the infectious fevers, 
especially scarlet fever and typhoid fever. 

Etiology. — Suppurative inflammation may be infectious from 
the start, or the infection may be secondary to any of the other 
varieties of tonsillar or peritonsillar inflammation. The super- 
ficial inflammatory process, or any condition which will lessen the 
physiological resistance of the epithelial layer, will predispose to 
infection. Constantly present in the mouth are bacteria, either 
pathogenic or non-pathogenic, and, while the mucous membrane 
is intact and the physiological resistance not lessened by inflam- 
matory processes, these germs are non-virulent; but when the 
membrane's resistance is lessened by inflammatory processes and 
there is accumulated material within the crypts of the tonsil, the 
non-virulent germ, under these suitable conditions, becomes viru- 
lent. The infection is usually by the staphylococci of suppuration 
and the streptococci. The associated germs are really not etiolog- 
ical factors in the suppurative process, but merely adjuncts. 

Pathology. — The pathological alteration is identical with that 
of catarrhal inflammation or inflammation involving mucous- 
membrane surfaces, and has been given in the chapter on General 
Considerations (page 51). The structure is one which is supported 
only from the back, thereby tending to rapid engorgement. The 
open lymphatic system permits of rapid spreading of the inflamma- 
tion, and nearly always with this infectious condition of the ton- 
sillar or peritonsillar structure there is enlargement of the chain 
of lymphatics extending down into the neck and also under the 
tongue — the cervical and sublingual glands. There is rapid infil- 
tration of the surrounding connective tissue with embryonal cells ; 
there is marked edema, owing to the blocking of the leukocytes 
and connective-tissue cells in the intercellular spaces ; and watery 
infiltration extending not only internally but externally. With 



TONSILLAR AND PERITONSILLAR ABSCESS. 483 

the infection and the rapid congestion, the part farthest from 
nutrition, being deprived of its blood-supply, undergoes coagulation- 
necrosis, and an abscess is often formed in the tonsillar or peri- 
tonsillar structure, identical with abscess-formation in any other 
structure. When the suppurative process is limited to the ton- 
sillar structure, there is less tendency to spreading in the line of 
least resistance, as is the case when it occurs back of the tonsil or 
in the peritonsillar structure. If spontaneous rupture occur, it 
will usually be in the most dependent part of the tonsil and open 
directly into the pharynx, while in the peritonsillar abscess the 
line of least resistance will be either anterior or posterior, follow- 
ing the course of the muscles toward the larynx, and may necessi- 
tate an incision through the entire tonsillar structure. 

Symptoms. — The symptoms of the tonsillar and peritonsillar 
abscess are very much the same, differing only in degree. The 
symptoms of an acute catarrhal or lacunar tonsillitis usually pre- 
cede the pus-formation. This may last from two to four days ; 
indeed, the acute symptoms may abate somewhat, when suddenly 
they reappear without any apparent cause, the patient becomes 
feverish and restless, there is perverted secretion, with dry mouth, 
failure of appetite, constipation with scanty urine. There is con- 
tinuous pain in the region of the tonsil, reflected not only into 
the ear but down into the laryngeal structure. This pain is 
increased on swallowing or on motion. The structures surround-* 
ing the tonsil will be red and edematous. This edema may extend 
over into the uvula and soft palate and down into the laryngeal 
and pharyngeal structure, with threatened edema of the glottis. As 
the structure goes on to suppuration, all of these symptoms will 
increase, swelling of the external tissues becomes more marked 
and deglutition more difficult, due to the inability of the patient 
to open his mouth. In some cases this condition closely resembles 
lockjaw. On account of the swelling and extreme pain on motion, 
the patient is unable to open his mouth. There is marked tender- 
ness externally at the angle of the jaw, with excruciating pain on 
pressure. At the onset there may be pronounced rigor followed 
by repeated chills, the breath is excessively foul, the tongue coated 
with a brownish, furry material. As a rule, the amount of pus- 
formation does not correspond with the severe and excessive clini- 
cal phenomena. Spontaneous rupture may occur at the most 
dependent portion, or in grave and especially infected cases there 
may be a necrosis and partial sloughing of the tonsil ; but, as a 
rule, the symptoms will demand surgical interference before such 
extensive necrosis can take place. Occasionally the suppurative 
process may be followed by ulceration ; but, as a rule, upon the 
relief of the pent-up pus the tissue goes on to rapid healing. 

In the tonsillar abscess the symptoms are almost identical with 



484 DISEASES OF THE TONSILS. 

the peritonsillar, although not so severe. The external swelling 
and glandular involvement, as a rule, are only slight. The sup- 
puration may not be localized, but there may be minute abscesses 
formed here and there through the tonsils. These may be deep in 
the structure and require puncture, or they may open sponta- 
neously. The fluctuation described by some writers is difficult to 
elicit on account of the extreme swelling and edema of the parts 
rendering all the structures tense, and, even if free access could 
be had to the tonsillar structure to admit of palpation, the pain 
would be so great as to preclude tnat means of diagnosis. The 
severity of the symptoms will depend largely on the systemic 
condition of the individual and whether there is any associated dis- 
ease. When occurring as a complication in measles, scarlet fever, 
typhoid fever, or influenza, it is apt to run a slower course and 
is usually of graver import. This is determined, however, by the 
generally bad nutrition of the individual. Fortunately, tonsillar 
and peritonsillar abscesses are generally unilateral, although both 
sides may be involved. 

Complications. — Serious complications may arise by the 
spreading of the abscess, through gravity and the line of least 
resistance, into the deeper cervical structures, thus causing pointing 
externally ; or from the surrounding inflammatory condition, with 
watery exudate into the intercellular spaces, there may be threat- 
ened edema of the glottis. By the pressure and swelling extend- 
ing up into the nasopharynx, the Eustachian orifice may be 
occluded, with subsequent middle-ear inflammation, or even sup- 
puration. If the abscess is deep-seated and there is extensive 
necrosis, there is a possibility of the involvement of the internal 
carotid artery, or even thrombosis of the jugular veins. However, 
these are exceptional complications. There may be thickening of 
the tonsillar structure as a result of the inflammatory process, with 
after-contraction, leaving the tonsil lobulated and irregular. Nearly 
always there is adhesion between the tonsil and the anterior and 
posterior palatine arches (Fig. 187). 

Diagnosis. — The diagnosis is based on the clinical phe- 
nomena — the external and internal swelling, difficult deglutition, 
pain in the ear, threatened edema of the glottis, inability to open 
the mouth — together with the previous history. The hypodermic 
syringe or aspirator is a useful instrument for diagnosis. Even 
where there is not marked external swelling, in all cases in which 
the patient is not able to open the mouth, peritonsillar abscess 
should be suspected, as there are several hospital cases on record 
in which the individual died of suffocation before a spontaneous 
opening of the abscess occurred, the conditions somewhat resem- 
bling lockjaw, thereby misleading the diagnostician. 

Prognosis. — As far as recovery is concerned, the prognosis is 



MEMBRANOUS INFLAMMATION OF THE TONSIL. 485 

good. This, however, is determined by the early recognition of 
the abscess and prompt surgical interference. 

Treatment. — Usually much relief can be afforded the patient 
before actual suppuration has occurred. A brisk purgative should 
be administered. There should be given internally 15- to 20-drop 
doses of tincture of chlorid of iron, either alone or in combination 
with glycerin, 10 to 30 drops. This should be administered every 
two hours for six or eight doses. A 10-grain Dover's powder given 
at bedtime affords great relief. Scarification of the tissue or deep 
puncture will relieve the tension, and in some cases may prevent 
suppuration. The tonsil should be opened with a sharp-pointed 
knife or curved bistoury, incision being made at the dependent 
portion or where, on inspection, the abscess shows evidence of 
pointing. The edge of the knife — except the actual cutting sur- 
face to be used — should be carefully wrapped with cotton or adhe- 
sive plaster, so as to avoid wounding adjacent structures. The 
knife, shown in Fig. 48 and Pierce's divulsor (Fig. 184), are well 
adapted for this purpose. Incision should always be made from 




Fig. 184.— Pierce's divulsor. 

the tonsil toward the pharynx, so as to be directed away from the 
blood-vessels lying external and anterior to the tonsil, thereby 
lessening the danger of wounding these structures. 

MEMBRANOUS INFLAMMATION OF THE TONSIL. 

Synonyms. — Membranous tonsillitis ; Fibrinous tonsillitis. 

There are a number of conditions of infection of the tonsil in 
which there is formed on the surface or within the crypts a mem- 
brane closely resembling that found in diphtheria. Frequently the 
caseous material forming within the crypts of the tonsil and extend- 
ing to the orifice will appear as a localized membranous inflam- 
mation. Again, in conditions associated with streptococcal infection, 
membrane is quite often formed on the pillars, on the tonsil, and 



486 DISEASES OF THE TONSILS. 

even on the pharyngeal wall. In gastric disorders and intestinal 
lesions the whole pharyngeal and faucial membrane may become 
reddened and inflamed, and frequently there are associated slight 
membranous patches. Membrane may form on the tonsil after the 
cautery or application of escharotics, or after tonsillectomy. 

The pathology of the condition is almost identical with 
that found when the infection is due to the Klebs-Loffler 
bacillus. There is a local coagulation-necrosis of the super- 
ficial epithelium, with surrounding areas of inflammation. Occa- 
sionally, from the absorption of the toxins manufactured by 
the staphylococci, streptococci, and pneumococci, which are 
nearly always present, there are marked systemic manifestations. 
Bacteriological examination of the mucous membrane of the 
throat shows clearly that even in health there are present 
numerous bacteria which under pathological conditions would be 
called etiological factors in the disease ; at the same time, with the 
mucous membrane normal these bacteria are non-virulent, and it 
is only when the physiological resistance of the membrane is les- 
sened by some inflammatory condition that the non-virulent bac- 
teria become virulent and pathogenic, and frequently, by micro- 
scopical examination, to the bacteria present are credited certain 
pathogenic properties, when in reality they are merely associated 
germs. The organisms present are in reality of secondary impor- 
tance. They are not so much etiological factors as is the inter- 
vention of some exciting cause, such as exposure, surgical operation 
on the tonsil, lesions of adjacent structures, or the lowered general 
vitality of the individual — the resultant localized inflammatory 
process forming a suitable nidus for the proliferation of the bacteria. 
The condition may progress, and, the deeper structures becoming 
involved, there will be produced localized ulcers, multiple or sin- 
gle, giving rise to the so-called ulcerative tonsillitis. This is more 
marked when the crypts are extensively involved. The ulcerative 
variety is not a distinct and separate variety, but the ulcers may be 
due to a number of causes ; they may occur in the ordinary simple, 
superficial inflammation, or may be associated with the parenchy- 
matous or lacunar variety. 

The symptoms are rarely very alarming, although from infec- 
tion through the lymphatics there may be enlargement of the glands 
of the neck, constant pain in the tonsil, increased by deglutition, 
offensive breath, partial loss of voice, due to the extension of the 
inflammation to the base of the tongue and the preglottic structures. 
Infection may lead to pharyngeal inflammation and possibly abscess- 
formation ; however, if treatment is instituted early, the complica- 
tions will be few. 

Treatment. — The treatment should consist in the thorough 
cleansing of the tonsil by antiseptic solutions, preferably by mop- 
ping the infected areas with a 15 volume hydrogen-peroxid solution, 






ENLARGEMENT OR HYPERTROPHY OF THE TONSIL. 487 

followed by a 1 : 500 pyoktanin solution, or, instead, the localized 
areas should be touched with a 3 to 5 per cent, solution of chlorid 
of zinc, or Loffler's solution. The intestinal tract should be thor- 
oughly cleansed with purgatives and salines, and the patient's 
general health should be improved by the administration of tonics. 

ENLARGEMENT OR HYPERTROPHY OF THE TONSIL. 

Synonyms. — Hyperplastic tonsillitis ; Hypertrophic tonsillitis. 

Of the enlarged or hyperplastic tonsil there are two varieties 
— one in which the structure is very soft (Fig. 185), and in which 
the increase in actual structure is largely of the glandular type, 
with very little alteration of the connective-tissue element ; while 
in the other variety there may be considerable increase in the 
actual gland-element, yet the most marked increase is in the con- 
nective-tissue stroma (Fig. 186), giving rise to the firm, hard, 
lobulated tonsil. It must be remembered that an enlarged tonsil 
does not necessarily mean an actual increase of tissue-elements in 
the sense of hypertrophy, or hyperplasia, or inflammatory thicken- 
ing, for the enlargement may be due to vascular changes, venous 
stasis, or watery infiltration into the tonsillar structure. It must 
also be borne in mind that in children the tonsils are normally 
large and that, because the gland-structure extends beyond the 
pillars of the fauces, the enlargement is not necessarily pathological. 
The term hypertrophy is commonly applied to any enlargement of 
the faucial tonsil, when, in reality, many of the enlargements are 
not true hypertrophies, but purely inflammatory or hyperplastic. 

Etiology. — The causes of the various enlargements of the 
tonsil cannot be classified under any one special head, as the 
increase in size may be due to a number of factors. The condi- 
tion is more common, however, in children of inherited strumous 
diathesis, or in individuals of acquired constitutional dyscrasiae. 
Inherited diatheses are often illustrated by the fact that several 
members of the same family have enlargement of the tonsil. A 
chronic inflammatory process, as a result of gouty or uric-acid con- 
ditions, is one of the common causes. The condition is practically 
one of childhood and early adult life, being most common at the 
age of puberty. Sex does not seem to exert any predisposing cause. 
Associated lesions of the throat are important etiological factors. 
Climate may predispose to local inflammation not only of the tonsil 
but of adjacent structures. The specific inflammatory processes act 
as predisposing causes through the lowered vitality produced by 
them. Because the tonsil possesses numerous crypts it is subjected 
to a greater amount of irritation and is more liable to chronic in- 
flammatory changes. The acute infectious diseases of childhood 
are frequently followed by chronic tonsillar lesions and permanent 
enlargement. Enlargement of the tonsil may also be due to inter- 



488 DISEASES OF THE TONSILS. 

ference with venous circulation. Especially is this true in cardiac, 
pulmonary, hepatic, renal, or intestinal lesions where there is per- 
version of the venous return or damming back of the returning 
circulation. This always produces cyanosis of mucous structures. 

When such conditions exist, there is an enlargement of the 
tonsil of the soft, boggy variety, which is largely due to watery 
infiltration or leaking of the serum from the blood-vessels into 
the surrounding structures, with a slow, chronic, inflammatory 
change. Repeated attacks of tonsillar or peritonsillar abscess are 
causative factors, the enlargement, however, being an inflammatory 
increase in the connective tissue. 

Pathology. — In hypertrophy of the faucial tonsil there is 
an increase in the glandular as well as the connective-tissue ele- 
ments. In the soft variety (Fig. 185) the glandular structure pre- 
dominates, and the clusters of glands are held together by a fine 
trabecula of connective tissue. The tissue, both glandular and 
connective, does not differ from the normal tonsillar structure. 
However, in some cases in which the chronic inflammatory proc- 
ess is more pronounced, the connective-tissue framework will be 
largely increased (Fig. 186) and dense in character, as is shown 
by the marked resistance on attempting removal with the tonsillo- 
tome. This marked fibrous character of the connective tissue can 
be explained by the organization of inflammatory material. The 
same fibrous-tissue formation will follow the cautery. If it were 
truly hyperplastic, although the connective-tissue element might 
be in excess, it would show no tendency to contract. In the varie- 
ties, then, in which the connective-tissue element is distinctly 
fibrous, the tonsil is markedly lobulated, the crypts are deeper 
and more irregular in shape, and by involvement in the fibrous 
contraction their openings may be decidedly narrowed. In this 
variety there would be an increased tendency to the accumulation 
of material within these crypts, which in turn will act as an irri- 
tant, bringing about further inflammatory reaction and tending to 
aggravate the condition. In the variety of enlargement in which 
the connective-tissue element is more hyperplastic in type and in 
which the contraction is less marked, the crypts are less saccular 
and not so prone to the retention of caseous material. In the 
enlarged tonsil, in which the increase in the structural elements is 
due to chronic irritation such as would be produced in a gouty 
or uric-acid diathesis, the tonsillar thickening is more regular 
and diffused throughout the entire gland-structure. When due 
to repeated inflammatory attacks, it is more irregularly fibrous, 
and hence, when contracting, produces a more irregular, lobu- 
lated tonsil. The soft, boggy variety is largely influenced by 
climatic conditions, as well as by the general vascular condi- 
tion of the individual. The soft variety and the true hyper- 
plastic variety usually atrophy in adult life; but occasionally 




Fig. 185.— Section of soft faucial tonsil (author's specimen). 




Fig. 186,-Section showing the hard fibrous tonsil after chronic inflammation, caustics, or 
cautery (author's specimen). 



ENLARGEMENT OR HYPERTROPHY OF THE TONSIL. 489 

this does not take place, and the individual is left with a per- 
manently enlarged tonsil. In an enlarged tonsil due to inflamma- 
tory thickening this physiological atrophy is less likely to occur, 
although the tonsil is often diminished in size by the contrac- 
tion of the organized inflammatory tissue — a pressure atrophy. 
The enlarged tonsil not showing any crypt is seen in Fig. 183. 
This last variety is also more likely to be associated with in- 
flammatory processes in adjacent structures, with the consequent 
organization of adhesions between the tonsil and faucial pillars 




Fig. 187.— Enlarged glands in the soft palate; also enlarged veins on the pharyngeal wall, 
with submerged tonsil. 

(Fig. 187). The symptoms produced by such adhesions are often 
productive of symptoms as grave as those of the enlarged tonsil. 
The tonsil of this character is likely to remain as a hard, fibrous 
mass, and with the resulting contraction of the inflammatory tissue 
be a constant source of irritation, producing symptoms similar to 
chronic pharyngitis. Besides, from the fibrous contraction there is 
glandular enlargement in the soft palate and pillars of the fauces, 
as seen in Fig. 187. 

Symptoms. — The tonsils may be so large as to fill the throat 
almost entirely. Cases have been reported in which they have 
touched, and from ulceration have become adherent one to the 
other. There is marked interference with nasal respiration, and on 
account of the enlargement of the tonsils there will be imperfect 
mobility of the uvula; on swallowing food and fluids, regurgita- 
tion into the nasopharynx will take place. Frequently the Eus- 
tachian orifice may be involved, either directly from pressure or by 
extension of the inflammatory process. On account of interfer- 



490 DISEASES OF THE TONSILS. 

ence with the nasal respiration, the child is apt to become a mouth- 
breather, with subsequent pharyngeal and laryngeal irritation. 
The facial expression is very similar to that of adenoid vegeta- 
tions, although not so pronounced. The child is restless at night, 
and is frequently disturbed by a rasping, hacking cough, brought 
about largely by mouth-breathing and its sequela?. Quite fre- 
quently, enlargement of the tonsil is associated with adenoid 
vegetations, and when such is the case, the symptoms as described 
in that chapter will be even more aggravated. The systemic 
effect of interference with nasal respiration will be marked ; 
the child will be anemic, languid, and mentally and physically 
below par. Not only is nasal resonance altered, but there is 
also marked interference with articulation, on account of the 
enlargement of the tonsil not only impeding the tone, but im- 
pinging upon the muscles of phonation, as well as those at the 
base of the tongue. Because of the probability of involvement 
of the Eustachian tube from the condition of the faucial tonsil, 
or from the associated enlargement of the pharyngeal tonsil, there is 
likely to be serious middle-ear lesion. Deglutition is markedly 
interfered with, especially in children. Although some question 
the fact that the faucial tonsil ever interferes directly with the 
orifice of the Eustachian tube, in some cases this undoubtedly 
does take place. If the Eustachian orifice were always in what 
is termed its normal location, this possibly would not often occur ; 
but it must be remembered that the position of the Eustachian 
orifice varies, and that in some cases it is quite low down and 
directly back of the posterior faucial pillar, where it would be 
subjected to pressure from an enlarged tonsil. With the enlarged 
tonsil, adhesions to the palatine folds are nearly always present. 
As these adhesions are of inflammatory origin and are always fol- 
lowed by contraction, the extent and location of the adhesion will 
have much to do with the macroscopical appearance of the tonsil. 
An enlarged tonsil may be more a source of discomfort than an 
actual disease. There is a constant sensation similar to that pro- 
duced by a foreign body in the throat, often combined with gastric 
phenomena, and the patient is easily nauseated. A number of reflex 
neuroses may be produced, especially bronchial and asthmatic 
cough. As a rule, all the symptoms are aggravated when the 
patient is in a recumbent position. The condition is rarely, if 
ever, congenital. Much has been said in regard to the tonsils as 
a source of infection and contagion. It is unquestionably true 
that the irregular nodular surface of the tonsil, with its numerous 
crypts, forms a suitable nidus for development of bacteria, and in 
the infectious processes involving the upper respiratory tract, ton- 
sillar involvement becomes a serious complication. The open 
lymphatic network gives free access to the absorption not only of 
pathogenic bacteria, but also of the toxins produced by them. 



SURGICAL TONSIL. 491 

Diagnosis. — The diagnosis of enlarged tonsil is not diffi- 
cult. The mere visual examination is usually sufficient. Digital 
examination will at once determine the character of the enlarge- 
ment. 

Prognosis. — Many cases of enlarged tonsil continue untreated 
through life ; some undergo physiological atrophy and leave 
behind practically no pathological alteration in the structure ; 
although, as a rule, if occurring early in life and allowed to pro- 
gress without surgical or medical interference, there is usually 
associated maldevelopment, in addition to permanent pathological 
alteration in the adjacent structures. The prognosis, from the 
standpoint of treatment, is good, either through medical or sur- 
gical interference. Occasionally, through anomalous blood-vessels, 
the ablation of the tonsil may lead to serious complication, giving 
rise to alarming and, indeed, fatal hemorrhage. 

Before taking up treatment as to removal of the tonsil, let us 
consider it as a surgical tonsil. 

SURGICAL TONSIL. 

The term "surgical tonsil" naturally implies a diseased tonsil ; 
not only a disease of the tonsillar structure, but its association 
with and involvement of surrounding structures. 

The large tonsil is not always necessarily a surgical tonsil. A 
fairly large tonsil may be entirely free from any diseased condition, 
not interfere with phonation, be free from any adhesions to the 
anterior or posterior pillars, and from its location does not involve 
by pressure the Eustachian tube. Such a condition is not neces- 
sarily a surgical tonsil, while a very small tonsil, bound down by 
adhesions, and in which there has formed back of the tonsil pockets 
filled with caseous material, the product of decomposed food and 
secretion — such a tonsil, although very small, is the source of con- 
stant absorption of poisonous material, and is decidedly a surgical 
tonsil. 

The imbedded tonsil which lies high up in the tonsillar fossa 
is a surgical tonsil because of location. Owing to its position high 
up in the fauces it interferes with free drainage of the Eustachian 
tube, also the free motion of the anterior and posterior pillars ; in 
other words, it interferes with the physiological function of the 
pharynx and nasopharynx. The adherent tonsil is surgical for 
the same reason. From repeated attacks of acute inflammatory 
processes involving the tonsil and the pillars, the surrounding con- 
nective tissue becomes greatly thickened, and from bands of adhe- 
sion which form between the pillars and the tonsil numerous 
pockets are formed, in which collects material which is a constant 
source of irritation. Besides, the muscular motion of the lateral 
walls of the pharynx is greatly interfered with. There is also, on 



492 DISEASES OF THE TONSILS. 

account of the infectious material retained within the tonsillar 
structure, great danger of infection of the cervical lymphatic 
glands. This is especially true in children. 

The cryptic tonsil, which may or may not be imbedded and 
adherent, is equally a surgical tonsil. While there is not so much 
involvement of the adjacent connective tissue as in the adherent 
tonsil, the constant source of infection is quite as marked, and the 
tonsil becomes a surgical one. 

In general, the laryngologists have not concerned themselves 
very extensively with the physiology of the tonsil or as to its value, 
when normal, as an arrestor of the entrance of pathogenic organisms, 
and that in early life it assists leukocytosis and gives off phago- 
cytes, losing these functions when diseased. Some consider it a 
lymphatic gland of no special function, and others as a producer of 
white cells when in a state of health, and several are of the opinion 
that it secretes an antitoxin and furnishes moisture to assist in 
deglutition, while some consider its function unknown. The 
majority are of the opinion that there is a direct relationship be- 
tween enlarged cervical glands and the tonsil, the tonsil being 
apparently the gland through which the infecting agent comes, as 
evidenced by the cessation of adenitis after removal of the tonsils. 
From the conflicting testimony on the subject of whether any con- 
nection exists between the tonsil and tuberculosis, it would seem 
that the question of the entrance of tubercle bacilli through the 
tonsil has not been sufficiently determined to render the fact an 
undisputed one. The relation of the tonsil to rheumatism presents 
an interesting field, complicated by the doubt as to the etiology of 
the disease. The investigations of the various authors show the 
possibility and probability of the tonsil as a portal of infection, and 
prove that whatever protection of the organism the tonsil may 
theoretically have it is practically of little value ; on the contrary, 
it is not infrequently a decided menace. 

The two important indications for the tonsil operation are : to 
remove the foci of infection and to increase or restore the functional 
efficiency of the respiratory, phonatory, and articulatory organs ; 
and the operation that fails to meet the requirements of these two 
indications is more or less a failure. The tonsil that requires re- 
moval is always prejudicial to vocal excellence ; but to do a little 
good in an operation one should take heed lest he do a great harm. 
To do a satisfactory tonsil operation is often quite as difficult as to 
do any other operation in the region of the throat, nose, or ear, and 
it requires quite as much skill. The tonsil operation, therefore, is 
the one of all others that should be done with great care and de- 
liberation. The popular belief that the removal of tonsils is injurious 
to the voice is well founded, and it is due in large measure to care- 
less or bad surgery. 

The indications for the removal of a tonsil, therefore, would be 



SURGICAL TOSSIL. 493 

based on a number of conditions : Whether it is obstructive and 
interferes with phonation and articulation, and whether it is dis- 
eased in any way and by absorption causes systemic phenomena. 
Recurrent attacks of tonsillitis, or peritonsillar abscess, regardless 
of cause, are always an indication for the removal of the tonsils. 
On the other hand, systemic conditions may cause involvement of 
the tonsil, and without directing treatment toward the relief of this 
underlying systemic condition, this systemic tendency to inflam- 
matory condition of the tonsil and peritonsillar tissue would not be 
relieved by the removal of the tonsil. True, the patient would 
not have an attack of tonsillitis after the removal of the tonsil, 
but in all these systemic cases the lymphatic ring around the tonsil 
and lateral walls of the pharynx would show the same inflam- 
matory condition after the removal of the tonsil, unless the under- 
lying systemic cause is removed,. In the rheumatic and lithemic 
type of individuals, who are subject to recurring attacks of tonsil- 
litis, the removal of the tonsils is indicated. 

The age of the patient is an important factor in the diagnosis 
of a surgical tonsil. In the young, under eight years of age, the 
tonsil is still a physiological structure, while in adult life this 
physiological function ceases. If the tonsil fails to atrophy, it is 
due to some pathological condition of the tonsil or its surrounding 
structures, either due to adhesions or pockets back of the tonsil or 
involvement of the crypts in the tonsil. Then, the structure having 
ceased its physiological function becomes a pathological tissue. 
The irritation caused by these pathological conditions keeps up a 
constant numerical increase of the tonsillar structure. By freeing 
the tonsil from its adhesions, and by opening the pockets or crypts, 
in many instances such a tonsil will rapidly atrophy, and the 
symptoms from which the patient had suffered will rapidly dis- 
appear. There are cases, however, in which there is a diseased 
tonsil as well as an underlying systemic condition, so that in such 
instances the removal of the tonsil will not relieve the patient of 
the attacks of sore throat. 

It is an important factor, then, in all these cases to determine, 
first of all, whether the involvement of the tonsil is a local or con- 
stitutional one, or both. 

The tonsil is also an important factor as to the question of voice. 
Degenerate tonsils are prejudicial to phonation, primarily because 
they are prejudicial to health, and secondarily because they inter- 
fere with the action of important vocal organs by setting up a 
catarrhal condition in the oropharynx, which results in hypertrophy 
of the faucial pillars, the plica, and the capsule, and in numerous 
inflammatory adhesions binding all these parts together in one con- 
glomerate mass. 

The position of the tonsil necessarily involves the muscles of 
articulation. By adhesions this may interfere with the correct 



494 



DISEASES OF THE TONSILS. 



execution of sound. On the other hand, the pharynx may be 
bulging at the point of the site of the tonsil, and during the mus- 
cular action necessary to the correct production of voice by that 
individual the tonsillar tissue may fill this bulging space when the 
voice is being used. The removal of such a tonsil would alter the 
voice. Also, when these muscles of articulation are in action, if the 
tonsil bulges into the anterior cavity, then the removal of the tonsil 
will improve the quality of the voice. 

Frequently, in cases of imbedded tonsils from inflammatory in- 
volvement, there are adhesions involving the tonsillar and peri- 
tonsillar tissue, and the contraction which follows such adhesions 
produces sensations of constriction and discomfort in swallowing, 
with alteration in the voice. In such cases relief can be obtained 
by breaking up the adhesions and thoroughly freeing the tonsil by 




Fig. 188.- 



-Set of tonsil instruments (Makuen's), consisting of two knives (right and left), 
one probe, and one curet. 



means of the instruments shown in Fig. 188, without necessitating 
the removal of the tonsillar tissue. 

Opinions differ considering the removal of the tonsil in the 
presence of tuberculosis, some holding that it is not only of no ad- 
vantage to do so, but that it is a serious disadvantage, in some 
cases hastening the tuberculous process. Personally, I think the 
interference with the tonsil when a tuberculous process is going on 
is a dangerous procedure. If there is no local infection, the opening 
up of the lymphatics and the laceration of the tissues may cause 
them to become infected after the operation, and healing may be 
delayed. If the process is a local one, the interference surgically 
might cause systemic infection. If the tonsil is the portal of ingress 
to the tubercular condition, and the individual is already infected, 
the removal of the tonsil would have no curative effect. However, 
if the tubercular process is arrested and for a time latent and no 
tubercle present in the sputum, then the tonsil should be removed. 



SURGICAL TONSIL. 495 

Operation. — Anesthetic. — Owing to the irritated condition of 
the mucous membrane of the upper respiratory tract in all cases 
of enlarged tonsils, especially when associated with the adenoid 
growths, the patient takes the anesthetic badly. The question of 
anesthetic is an important one. In certain parts of our country 
chloroform is used extensively. In my own practice, however, I 
almost invariably use ether anesthesia, and in all cases the patient 
should be profoundly under the anesthetic, so that all parts are 
thoroughly relaxed. 

Posture. — In regard to the position of the patient for the tonsil 
operation, the majority of surgeons prefer the dorsal for children 
under general anesthesia ; some favor the prone position, one side 
or the other, a few the semirecumbent, and a few the Rose and 
Trendelenburg positions. Personally, I prefer the patient in the 
dorsal position under complete anesthesia. 




Fig. 189.— Modified Watson's tonsil-grasping forceps. 

Technic. — The trend of reports favors the complete enucleation 
of the tonsil with the capsule, the technic varying with the indi- 
vidual operator. 

When the patient is completely anesthetized the mouth-gag is 
introduced; the one shown in Fig. 178 I find to be most satis- 
factory. 

Before beginning the dissection of the tonsil the entire surface 
should be carefully palpated to determine whether or not there is 
present any anomalous blood-vessel. By locating any such vessel 
severe hemorrhage may be averted. 

In the removal of a tonsil the tonsillar tissue should be care- 
fully dissected from the anterior and posterior pillars, as any lacer- 
ation of these pillars will cause a certain amount of scar formation. 
This scar formation, then, will later interfere with the muscular 
structure of the lateral pharyngeal wall, and, therefore, interfere 
with perfect phonation and execution, both in the singing and 
speaking voice. 



496 



DISEASES OF THE TONSILS. 



The tonsillar tissue should be grasped by means of the tenaculum 
forceps, as shown in Fig. 190, and traction made toward the median 
line of the pharynx. The entire tonsillar mass may then be clearly 
outlined and palpated, and the resistance offered by the tissue will 
show clearly the points of adhesion. The tonsillar capsule can 




Fig. 190.— Adherent and submerged tonsil. 

then be split from top to bottom by means of the tonsil knife, as 
shown in Fig. 191. The tonsillar tissue can be dissected free from 
the anterior and posterior pillars. Great care should be exercised 
to preserve the pillars, no matter how irregular the structure may 
be, as any destruction of these will be followed by scar formation, 




Fig. 191.— Stevens' tonsil-knife. 



and will necessarily interfere with the muscular action of the pillars 
and soft palate, thereby interfering with phonation. During the 
process of freeing the tonsil, traction is kept up by means of the 
tenaculum forceps, and when the tonsil is entirely freed it will 
completely evert itself from the tonsillar space, as shown in Fig. 
197. The snare is then placed over the tonsillar structure, care 



SURGICAL TONSIL. 



497 



being taken that none of the surrounding tissue is impinged within 
the grasp of the wire, and also that the uvula is perfectly free ; and 
before tightening the wire around the tonsil care should be taken 
to have the line of the cutting surface parallel to that of the lateral 
pharyngeal wall, so that a smooth base of the tonsil will be left. 

In my own experience the snare is the most satisfactory instru- 
ment for the removal of the tonsil. However, in exceptional cases, 




Fig. 192.— Pierce's tonsil-punch. 

the Pierce tonsil-punch,, as shown in Fig. 192, or the Farlow tonsil- 
punch, as shown in Figs. 193 and 194, are useful instruments, 
where for any reason the tonsil should be removed piecemeal. 

After-treatment. — The patient is returned to bed and carefully 
watched for any bleeding. The nose and throat receive no local 
treatment whatever. If desired, mild alkaline astringent gargles 
may be employed the day following operation. The patient is 




Fig. 193.— Farlow's oval tonsil-punch. 



allowed to leave the hospital the second or third day after oper- 
ation. 

Hemorrhage. — The sources of danger from hemorrhage after 
the excision of the tonsil are : 1, An anomalous ascending pharyn- 
geal artery ; 2, an anomalous tonsillar artery ; 3, a large artery in 
the anterior pillar ; 4, an enlarged venous plexus at the lower 
border of the tonsil, really dilated veins from stasis ; 5, large 

32 



498 



DISEASES OF THE TONSILS. 



patulous tonsillar arteries. It is to be remembered that, as a rule, 
there is considerable hemorrhage at the time of operation. 

In considering the subject of hemorrhage after the removal of 
the tonsil, the age of the patient is an important matter. Nearly 
all cases of alarming hemorrhage have been in adults, and most of 
the cases of severe hemorrhage have occurred after rapid removal 
of the tonsil by the bistoury or sharp tonsillotome. The danger 
of secondary hemorrhage in children is not as great as in adults, 
on account of there being a less amount of fibrous tissue in the 
anterior and posterior pillars. 

By the snare method there is much less danger of hemorrhage. 
The removal of the tonsil with the thermocautery snare also lessens 
the danger of profuse bleeding. The objection to this method is 




Fig. 194.— Farlow's tonsil-punch. 



that besides the cut there is added a burn, with the possibility of 
secondary hemorrhage when the slough comes away. 

However, this complication may arise at any age, and after the 
tonsil is removed the parts should be thoroughly inspected for any 
bleeding point, and the patient should not leave the operating-table 
until all bleeding has been arrested. . Should secondary hemorrhage 
occur other than oozing, the best plan of procedure is to at once 
ligate the bleeding point. In all cases of removal of the tonsils 
and adenoids, the nurse should be instructed to watch carefully for 
any oozing, which may occur following the operation, as a number 
of cases have been reported, and one or two have occurred in my 
own practice in which from continual, gradual oozing the patient 
had lost a great amount of blood before the danger was suspected. 

One of the best styptics to be applied to the tonsil is a 10 per 
cent, alumnol solution. Ice-water spray or adrenalin chlorid is 
good. A useful astringent is 6 grains of tannic acid and 8 grains 



SURGICAL TONSIL. 



499 



of alum to the ounce of water. If the bleeding is due to a patulous 
artery which can be located and grasped, it should be twisted or 
ligated. Internally, for the relief of continued oozing, 1-grain 
doses of ergotin, given every two hours for three or four doses, will 
be of service. Occasionally alarming secondary hemorrhage mav 
occur, necessitating ligation of the bleeding vessels or suturing of 




Fig. 195.— Corwin's tonsil hemostat. 

the pillars. For immediate arrest of the hemorrhage in case of 
emergency, Corwin's tonsil hemostat (Fig. 195) or Pierce's tonsil- 
clamp (Fig. 196) should be used. Another source of danger is the 
condition known as hemophilia, found in persons ordinarily known 
as "bleeders"; it is often difficult to obtain this knowledge, how- 
ever, before operation. While alarming hemorrhage is of rare 




Fig. 196.— Pierce's tonsil-clamp. 



occurrence, yet in the removal of the tonsil its possibility must 
always be remembered. 

A great variety of experience is reported with reference to the 
question of hemorrhage. In addition to hemorrhage, injury to the 
uvula, pillars, or palate, quinsy from incomplete operation and as 
a result of injury with the snare, double otitis media with double 



500 DISEASES OF THE TONSILS. 

mastoiditis, and acute otitis media were some of the accidents 
reported. 

The question of injury to the voice following the removal of the 
tonsils is spoken of guardedly by those who have had most ex- 
perience with professional singers, admitting that for the time, at 
least, there is an alteration in the voice, followed later, as a rule, 
by improvement, most of them holding that higher tones are ob- 
tainable than before. In some instances there is no question that 
the range and volume of the voice are increased, provided the 




Fig. 197.— Showing tonsil drawn forward by means of tenaculum forceps and line ot 
incision into the tonsillar tissue. 

pillars are uninjured, after complete tonsillectomy, as in many 
cases the tonsil, by its firm attachment to the pillars, especially if 
enlarged, hindered the mobility of the muscles. 

Another method, which is used by myself and my assistant, Dr. 
Fielding O. Lewis, at the Jefferson Hospital, we find very satis- 
factory. There is less hemorrhage, less traumatism to the sur- 
rounding structure, and less danger of adhesions following the 
operation. It is especially adapted for cases to be performed under 
local anesthesia. 






SURGICAL TONSIL. 



501 



Technic of Operation. — The tonsil is grasped as near the 
center as possible, with a modified Watson tenaculum forceps, as 
shown in Fi^s. 189, 198. 




Fig. 198.— Showing tonsil everted and snare in position ready for cutting. 

The tonsil is pulled, by traction on the forceps, toward the mid- 
line of the pharynx. An inverted U-shaped incision is now made, 
with the base of the U at the upper pole of the tonsil. The in- 



^F.CO.OFPn.' 



Fig. 199.— XeAv tonsil knife. 



cision is made by a suitable tonsil knife, such as is shown in Figs. 
191, 199, beginning at the base of the tonsil, in front of the pos- 
terior pillar. It is made in the tonsillar tissue itself, and extends 
around the upper pole of the tonsil and behind the anterior pillar 



502 



DISEASES OF THE TONSILS. 



to a point opposite the beginning of the incision. The tonsillar 
pillars are not touched and no dissection is necessary. The tonsil 
is then grasped deeply, with the same forceps, within the incision ; 
a strong traction is now made and the tonsil is seen to evert over 

the anterior and posterior pillars, re- 
sembling somewhat the form of a cauli- 
flower. The tonsillar snare, as shown 
in Figs. 198, 200, is now placed around 
the base of the tonsil, and by sudden 
or gradual constriction of the snare loop 
the capsule of the tonsil is separated 
from the superior constrictor muscle. 

On examining the tonsil after its re- 
moval its capsule will be found intact. 

Sluder's Operation for Tonsillec- 
tomy. — Dr. Greenfield Sluder uses a 
modification of the so-called Mackenzie 
guillotine, which instrument, as a mat- 
ter of fact, was first described by Dr. 
Physick, of Philadelphia, in 1827. Of 
the numerous modifications of the in- 
strument in rendering it adaptable to 
Sluder's technic, the author prefers the 
one shown in Fig. 201, which, in addi- 
tion to the sliding blade passing over a 
rigid elliptical ring, possesses a snare 
so arranged that when the tonsil has 
been engaged in the rigid opening by 
manipulation and partial descent of the 
blade its further removal is effected by 
means of the wire loop which lies be- 
tween the ring and wall of the throat. 

As to his technic, Sluder states that 
" the essential and only original features 
of this method consist in dislocating the 
tonsil out of its soft movable bed in a 
direction upward and forward to the 
point where is met the eminence on the 
inner side of the lower jaw made by the 
last-formed molar tooth in its socket 
with the gum covering it, to which I 
have given the name l alveolar eminence 
of the mandible' (Fig. 202), in putting the tonsil through the guil- 
lotine by the eminence alone or by the aid of the finger on the 
anterior pillar. In order to use the alveolor eminence of the man- 
dible as a vantage point from which to manipulate the tonsil — that 
is, to use this prominence to put or help put the tonsil through the 





Fig. 200.- 



-Lewis' improved tonsil 
snare. 



SURGICAL TONSIL. 



503 



aperture of the guillotine — it is necessary to move it completely 
from its normal position which is posterior to and below the emi- 
nence. It must be moved forward and upward. The elasticitv 
of the soft parts of the throat readily allow the necessary movement. 
In this way the tonsil will be moved out of a hollow, soft, moving 




Fig. 201.— Distal end of combined guillotine and snare, showing snare-tip with wire loop 
lying on top of guillotine blade (Sluder). 

bed and be brought up on to a motionless, hard nump — a solid, 
fixed, somewhat hemispherical convexity. Regardless of what may 
be the position of the patient's head, the surgeon takes his bearings 
from the lower jaw. The guillotine, with the transverse axis of the 
aperture vertical, is introduced into the mouth at an angle of 45 
degrees outward and backward, passing back until the distal arc 




.roximate position, 
of Tonsil 



Fig. 202.— Inner surface of the right half of the mandible, showing the alveolar emi- 
nence, A, and its relation to the usual position of the tonsil (Sluder). 



of the aperture is completely behind the tonsil. The instrument 
at this moment may sometimes to advantage be rotated slightly by 
turning the handle downward (toward the feet). This tends to 
enlarge the field of vision. It is then pressed outward until the 
distal arc of the aperture has been pressed against the ramus of the 
jaw. It is now brought slightly forward and upward, but held firmly 



504 DISEASES OF THE TONSILS. 

against the bone and muscle, when it will be seen that the lower 
distal arc of the aperture has acted very much like a scoop, having 
secured the lower part of the tonsil, and brought it forward and 
upward on to the eminence of the alveolus. The blade is now 
pushed down with the gentlest possible pressure until the surgeon 
sees that it is in contact with the tissues. It should not be pressed 
forcibly until the parts are engaged satisfactorily in the aperture. 
The blade, being in contact with the tissues, prevents the portion 
of the tonsil which has gone through from slipping out again. At 
this moment the surgeon may perceive that although the distal arc 
of the aperture is entirely behind and external to the tonsil, a part 
of its anterior portion has still not gone through. This is usually 
readily seen, but may be more definitely determined by feeling with 
the tip of the index-finger of the other hand, and at the same time 
it may be pushed through. This is done by the gentlest massage — 
simply stroking it in the direction of the aperture with the ball of 
the index-finger, and at the same time pushing the blade very gently 
across the remaining portion of the aperture. All of the tonsil 
having gone through, the blade is pushed across with all the power 
of the surgeon's hand. Great pressure is usually required because 
the blade has been made dull. ,, 

Supposing the operator's technic to have been perfect, the tonsil 
with its investing capsule will be found to have been removed in 
its entirety. 

Finger Enucleation of the Tonsil. — Personally, I practice 
this method very seldom. However, a number of excellent oper- 
ators highly endorse the method. 

Dr. Charles W. Richardson's method of removing the tonsils 
by finger enucleation is as follows : " First, it must be remembered 
that in the manipulation the finger-nail is not to be used as a cutting 
instrument, nor should it enter in any degree into the operative 
procedure. After the patient is thoroughly anesthetized through 
the agency of ether and a well-retaining mouth-gag is in place — 
preferably the modified Whitehead's without tongue depresser — the 
operator is prepared to proceed. The index-finger seeks the free 
border of the anterior pillar of the fauces (Fig. 203) as it rests against 
the tonsil in its upper third, and, by gentle pressure, the pillar is 
forced from the tonsil and the mucous membrane between the tonsil 
and the pillar broken through. In this manipulation, after the pillar 
is raised and the finger is insinuated between it and the tonsil, all 
pressure must be made outwardly and posteriorly against the tonsil 
rather than against the pillar. The operator must also be extremely 
cautious in this preliminary procedure that he engages the finger 
between the free border of the pillar and the tonsil and does not 
penetrate through a portion of the anterior pillar, which one is so 
apt to do unless exercising due caution. After the finger breaks 
through the mucous membrane between the tonsil and the pillar, 



SURGICAL TONSIL. 



505 



there is imparted a sensation of the complete loss of resistance as 
though one were entering a cavity. This point having been ob- 
tained in the operative procedure, the finger is swept behind the 
capsule and the loose connective tissue which binds the capsule of 
the tonsil to the constrictor muscle is broken away and the upper 
lobe of the tonsil is forced out of its position behind and above the 




Fig. 203.— Index-finger seeking border of anterior pillar (Richardson). 

upper commissure. The finger now engages itself completely be- 
hind the partially enucleated tonsil and gradually strips it down- 
ward to the floor of the tonsillar fossa. It is usually my habit in 
the final stage of the operation to grasp the now nearly separated 
tonsillar mass with a strong pair of forceps and with these draw T 
the tonsil firmly inward toward the fauces (Fig. 204), while at 




Fig. 204.— Tonsil grasped in forceps while finger completes the dissection (Richardson). 

the same time the finger is insinuated between the tonsil and the 
fossa and thus breaks away the few remaining strong fibrous 
bands at this point, which, through the traction inward, are more 
defined and thus more readily separated. When all fibers are 
practically separated, a quick traction on the forceps completes 
the enucleation. The same purpose may be accomplished by en- 



506 DISEASES OF THE TONSILS. 

circling the tonsillar mass so separated by means of a snare. As 
stated above, it is greatly to be desired in the preliminary pro- 
cedure to insinuate the finger between the free border of the pillar 
and the tonsil, otherwise there will be more or less loss of the inner 
border of the anterior pillar in the operation. This separating and 
safeguarding of the anterior pillar is not always as easy a procedure 
as one would think, as the inner edge of the pillar is frequently 
very thin and as frequently rides over the anterior 
rounded contour of the tonsil, so as to make it nearly 
impossible not to sacrifice a bare margin of its 
free border. When the free border of the anterior 
pillar is ill-defined, very thin, or is lost in the 
rounded contour of the tonsil it may be of advan- 
tage, when the operator's finger is thin and narrow, 
to commence the procedure by insinuating the finger 
between the pillar at the upper commissure and 
the tonsil from above and then gradually strip 
it downward from its bed. Due care must be 
exercised, also, in the preliminary procedure not 
to use such force on the tonsil as to break through 
the capsule into the tonsil rather than through 
the mucous membrane fold, as this misfortune — 
unless one is quite expert — leaves the operator 
in almost a helpless position. When one feels 
M unsafe in using the finger for the preliminary 

breaking through of the mucous fold between the 
tonsil and the anterior pillar, the Douglass or other 
form of blunt separator may be used for this purpose. 
In using the Douglass separator the tongue must be 
well depressed. The only objection to the use of 
the separators is the possibility of penetrating the 
capsule. Adhesions are very rare either between 
the anterior pillar and the tonsil or the posterior 
pillar and the tonsil. When adhesions exist, due 
caution must be exercised in the stripping that the 
substance of neither pillar is included. The most 
frequent seat of, and the most annoying type of 
adhesion, is in and behind the upper commissure 
in cases which have had frequent recurrent attacks 
of peritonsillar abscess. To overcome these at 
times dense fibrous bands it becomes necessary to 
Fl( dissector! hs ' use the Douglass separator, or knife or scissors. 
The cavity should be carefully examined to insure 
that all tonsillar tissue, especially in the floor of the commissure, 
has been removed, and measures should be adopted to insure an 
absolutely dry cavity before the patient is removed from the 
operating-table." 



SURGICAL TONSIL. 



507 



Dr. George F. Doyle has practised finger enucleation for sev- 
eral years and his technic is as follows : 

Ether anesthesia is employed. The patient is placed in the 
dorsal posture, without pillow, the head turned slightly to the 
right. The mouth-gag is introduced and the tongue depressor in- 
serted. The tonsil is grasped in the center by means of straight 
forceps and traction made in the direction of the median line, 
which outlines the entire tonsil and makes the anterior pillar 
and plica triangularis tense. The tongue depressor is now trans- 
ferred to the assistant, who holds the tongue well depressed and 
toward the opposite side, away from the field of operation. The 
point of the Allis dissector is . introduced beneath the mucous 
membrane of the plica triangularis at its lowest point, and this 




Fig. 206.— Showing separation of the plica triangularis (Doyle). 

membrane is separated from below upward, slightly internal to 
and parallel with the margin of the anterior pillar (Fig. 206). 
The separation of the plica triangularis is the most important 
part of the operation, as upon this step depends the ease and 
success with which the succeeding maneuvers can be carried out. 
Care must be exercised in the separation of the plica so as not to 
penetrate the capsular structure beneath the mucous membrane. 
The capsule of the tonsil must remain intact, as otherwise the 
separation will be intracapsular and the tonsillar tissue will pull 
apart from the traction made upon it, and it will be very difficult 
to accomplish an extracapsular enucleation. After having sepa- 
rated the plica, the anterior pillar can be readily retracted over the 
anterior surface of the tonsil by means of the Allis dissector. The 
index-finger is now introduced between the posterior surface of the 



508 



DISEASES OF THE TONSILS. 



anterior pillar and the capsule of the tonsil (Fig. 207) and carried 
upward and backward around the velar lobe, and continued down- 




Fig. 207.— Showing finger dissection of the tonsil (Doyle). 

ward and forward between the capsule and the anterior surface of 
the posterior pillar, thus entirely separating the tonsil with its cap- 




Fig. 208.— Showing tonsil lifted completely out of the tonsillar fossa (Doyle). 

sule, with the exception of the pedicle by which it remains attached 
at the lower pole. The tonsil can now be lifted completely out of 



CASEOUS TONSILLITIS. 509 

the tonsillar fossa, as shown in Fig. 208. The snare is now applied 
to the pedicle and the tonsil removed, after which the tonsillar 
fossa is inspected for hemorrhage. If the finger dissection has 
been properly carried out, there is absolutely no danger of includ- 
ing the pillars or the uvula in the wire loop of the snare, as the 
tonsil can be drawn well away from these structures. If the pa- 
tient has been thoroughly anesthetized at the beginning of the 
operation, both tonsils and the adenoids can be removed without 
further administration of the anesthetic. The patient is returned 
to bed, placed on the right side with a pillow under the shoulder, 
so that should there be any postoperative hemorrhage it will be 
detected immediately, as the blood will drain from the mouth. 
The nose and throat receive no after-treatment whatever. The 
patient is allowed to leave the hospital the day following the 
operation, provided the temperature, pulse, and respiration are 
normal. 

CASEOUS TONSILLITIS. 

This variety of inflammation of the tonsil is really mechanical 
in its origin. It has also been described by some writers under 
cholesteatomatous disease of the tonsil, or cholesteatoma of the 
tonsil. Either from pre-existing inflammatory process or from 
enlargement of the tonsil with consequent increased depth of 
its crypts (Fig. 183), which have been altered by catarrhal 
inflammatory processes, pockets of varying size form here and 
there over the tonsil. The location of these pockets, as a rule, 
is in the lower portion of the tonsil. However, frequently 
from adhesions after tonsillar and peritonsillar inflammations a 
pocket may be formed high up, and can be demonstrated only 
by drawing the tonsil out, or is sometimes shown by the 
patient when gagging is produced by the use of the tongue- 
depressor. In these pockets, secretions and particles of food 
accumulate, which in themselves act as foreign bodies, and by 
the presence of bacteria of fermentation, as well as pathogenic 
micro-organisms, an irritation is set up, which will produce inflam- 
matory processes in the surrounding structures. The usual history 
of these cases is one of repeated attacks of sore throat, a pricking 
sensation in the tonsil, with occasional discharge of minute masses 
of foul-smelling caseous material. These little masses are usually 
referred to by the patient as " peas." Quite often the patient is 
able to relieve the tonsil of the accumulated secretion by pressure 
externally, at the same time passing the finger quickly over the 
tonsil and pressing forward ; but frequently the masses become 
retained through the occlusion of the orifices by acute inflamma- 
tion. The symptoms in the aggravated cases closely resemble 
those of tonsillar or peritonsillar abscess, although they are more 
prolonged and less severe. 



510 DISEASES OF THE TONSILS. 

Occasionally the mass may become healed in, and not infre- 
quently there will be seen in the tonsil a peculiar grayish-white 
nodule of which the patient is not aware. On puncturing there 
will flow out a semi-fluid material which is most offensive. 
This is nothing more than a healed-in crypt. Occasionally there 
may be deposited in these pockets, along with the caseous material, 
an excess of lime salts, which in time form a calculus known as a 
tonsillolith or amygdaloliih. Quite frequently, from adhesion at 
the base of the tonsil with the anterior pillar, there is formed 
behind it one of these pockets which is not included in the tonsil 
— really peritonsillar. Where the tonsils are very much enlarged 
and not only slightly cryptic, on account of the relation of the 
pillars to the tonsil, the crypt may be buried behind the pillar or 
it may be formed at the upper portion of the tonsil and back 
of the tonsil. An examination by ordinary means would fail to 
show these pockets, but by drawing the pillar forward by means 



Fig. 209.— Small tenacular-forceps. 

of the pillar retractor or an ordinary curved applicator the pocket 
can be located and the caseous material removed. Frequently 
an attack of tonsillitis can be aborted in this manner. The crypt 
originally may have been a perfectly healthy one, but owing to its 
location and relation to the pillar, free drainage was not allowed 
and the crypt enlarged, owing to the accumulation and second- 
ary inflammatory process which followed. 

Treatment. — The treatment consists in the free opening of 
the crypts or pockets. The pockets should be slit from top 
to bottom and should be carefully mopped out with carbolic-acid 
solution or thoroughly curetted, so that in the healing process 
their entire obliteration will occur. In spite of careful watching, 
minute pockets may be formed after healing has occurred and con- 
nective-tissue contraction has taken place. Should this happen, 
the pocket formation should be treated in the same manner as 
before. If, however, the tonsil is markedly enlarged, then 






GANGRENE OF THE TONSIL. 511 

there should be thorough removal of the tonsillar tissue. The best 
instrument for this purpose is the Farlow punch, as shown in 
Fig. 194. If there is any adhesion between the tonsil and the 
anterior and posterior pillars these should be thoroughly freed by 
means of the Stevens tonsil- knife, as shown in Fig. 191. This 
can be very easily accomplished if the tonsil is grasped by the 
small tenacular-forceps (see Fig. 209) and pulled directly out 
toward the median line of the pharynx. The adhesion then 
should be dissected free, following the outline of the pillars. All 
irregularities will disappear after the inflammatory process has been 
relieved. The tonsil is then removed piecemeal by means of the 
biting forceps. Care should be taken to thoroughly clean out the 
upper portion of the tonsillar capsule. 

CHRONIC ABSCESS OF THE TONSIL. 

A few cases of chronic abscess of the tonsil have been described. 
From the clinical history as given and from two cases coming 
under my own observation, I believe the condition to be due to a 
caseous crypt rather than a pyogenic process. However, it is 
possible in tubercular processes to have the so-called encysted 
abscess. 

The treatment should consist in incision, thorough curetment 
of the limiting membrane, with cauterization of the entire surface. 

ATROPHY OF THE TONSIL. 

As a rule, atrophy occurs as a physiological process from the 
twelfth to the eighteenth year. Should it occur as a pathological 
process, it is of little clinical significance. After repeated attacks 
of tonsillar and peritonsillar inflammation, with marked adhesion 
to the faucial pillars by the contraction which follows the organ- 
ized inflammatory tissue, there may be a limitation of the blood- 
supply, causing a simple pressure-atrophy of the tonsillar structure. 
A similar condition may be brought about by linear cauterization 
or scarification of the tonsil. 



GANGRENE OF THE TONSIL. 

Gangrene of the tonsil is a rare condition. Few cases have 
been reported. Of these few a number have been fatal. 

The etiology of the disease is obscure ; no particular micro- 
organism can be cited as the etiological factor. In some cases 
the gangrenous mass involved the entire tonsil, in others only a 
portion of the tonsil. Personally, I have seen only two cases 
of this rare disease. Both were observed in my clinic at the 
Jefferson Medical College Hospital and in both cases the gangren- 



512 DISEASES OF THE TONSILS. 

ous area was limited to one tonsil. The mass sloughed off and 
the tissue gradually healed, forming considerable scar tissue. The 
patient had very slight systemic symptoms, and, as far as I 
was able to observe, made an uninterrupted recovery. Although 
in neither case did the entire tonsil slough off or become gangren- 
ous, neither was there any involvement of the surrounding tissue. 
Both cases were in poor physical condition, and one case had 
an almost direct latent specific history. Richardson, of Washing- 
ton, reports two fatal cases. 

MYCOSIS OF THE FAUCIAL TONSIL. 

This mycotic affection of the tonsil is often due to the Leptothrix 
buccalis, which attacks the outer layer of the epithelium and gives 
rise to yellowish or yellowish-white patches, sometimes within the 
crypts of the tonsil, but more frequently about their orifice. The 
condition is really a coagulation- or liquefaction-necrosis of the 
superficial epithelial layer. It may extend to the pillars of the 
fauces, or even to the pharyngeal surface, and is often associated 
with a similar condition at the base of the tongue (the lingual 
tonsil). As etiological factors there are frequently associated 
lesions of the intestinal tract, especially of the stomach. Lesions 
of the mouth, especially carious teeth, may be associated, although 
the decay of the teeth may really have been the cause of the gas- 
tric disorder. The condition gives very little inconvenience to 
the patient ; indeed, it is usually discovered by accident. Occa- 
sionally it may cause a pricking sensation very much the same as 
in caseous tonsillitis. Microscopical examination will determine 
the diagnosis. 

Prognosis. — The affection itself is not serious, but the mycotic 
areas soon re-form after their removal. It seems to resist any but 
continuous treatment. 

Treatment. — All diseased teeth should be carefully treated 
and any intestinal or gastric disorders corrected. The localized 
areas should be cleansed with hydroden peroxid (15 volume), 
carefully dried, and each individual area touched with tincture of 
iodin, which should be repeated every day until cure is effected. 
Resort to the actual cautery may be necessitated in some cases. 

ACTINOMYCOSIS OF THE TONSIL. 

Actinomycosis of the tonsil is an exceedingly rare condition. 
A very few cases have been reported in which microscopical findings 
proved the diagnosis. The infection germs seem to have found 
ingress through the tonsillar crypt. The disease, when located in 
the tonsil, does not differ in pathology or treatment from its de- 
scription elsewhere. 



LINGUAL TONSIL. 513 



FOREIGN BODIES IN THE TONSIL. 

The location and structure of the tonsil, as well as its frequent 
enlargement, render it especially liable to lodgement of foreign 
bodies, such as spicules of bone, pins, fish-bones — in fact, any 
pointed foreign material. The symptoms produced are identical 
with those of a foreign body in the pharynx or at the base of the 
tongue. On inspecting the tonsil for foreign bodies, care should 
be taken to produce very little muscular contraction or spasm, and 
efforts should be made, as far as possible, to keep the parts relaxed, 
as the foreign body may be so located that by muscular contrac- 
tion it may be thrown behind the faucial fold, thus hiding it from 
view, whereas if the parts are relaxed it will project into the 
pharynx and be readily seen. 



LINGUAL T0N5IL. 

1. Acute Inflammation (Preglottic Tonsillitis). 

2. Acute Phlegmonous Inflammation (Abscess). 

3. Hyperplasia. 

4. Mycosis. 

5. Varices. 

a. Regular Dilatation. 
6. Saccular Dilatation, 
c. Idiopathic Hemorrhage. 

Synonym. — Buccal tonsil ; Fourth tonsil. 

On the base of the tongue (Fig. 1), behind the circumvallate 
papilla? and above the attachment of the epiglottis, are a series of 
rounded elevations composed of adenoid tissue — the lingual ton- 
sil. In the center of each elevation is a small orifice leading into 
a central cavity or crypt which is lined with stratified pavement 
epithelium, and is surrounded by a layer of adenoid tissue which 
is supported by the normal connective-tissue elements of the part. 
At the bottom of each crypt is the orifice of the duct of a mucous 
gland. 

The importance of this structure, from a physiological and 
pathological standpoint, is frequently overlooked. Situated as it 
is at the base of the tongue, it has an intimate vascular and lym- 
phatic relation with that organ, the upper portion of the larynx, 
the pillars of the fauces, and the lateral pharyngeal walls. It 
consists of a number — usually from ten to twenty — of glandular 
masses of the modified racemose variety. Its location renders it 
liable to irritation from food and drink, and it tends, like other 
gland-structure, to direct or indirect alteration, dependent upon 
systemic or associated local lesions. 

33 



514 „ DISEASES OF THE TONSILS. 



ACUTE INFLAMMATION. 

Synonym.— -Preglottic tonsillitis. 

Etiology. — The usual pathological alteration occurring in 
this gland-structure is an acute or chronic inflammatory process — 
a secondary result of some constitutional diathesis. It may 
accompany and follow the infectious fevers ; or it may be involved 
in the specific inflammatory processes, especially tuberculosis and 
syphilis. Frequently the inflammatory condition persists after an 
attack of influenza, especially that variety attacking the upper 
respiratory tract. Stomachic conditions, especially acid indiges- 
tion associated with eructation of gases, intestinal lesions such as 
constipation, with interference of venous circulation and the reab- 
sorption of irritating materials into the blood, are also important 
etiological factors. The uric-acid diathesis, in which the entire 
mucous- membrane surface is also subjected to irritation, is an 
important factor. Habitual users of tobacco, either smokers or 
chewers, are frequently sufferers from inflammation of this gland- 
structure. 

Enlargement or any inflammatory condition of the lingual ton- 
sil, owing to the accumulated secretion and the constant irritation 
present, may be the cause of persistent and hacking cough. This 
is especially true in children. Owing to its location, it is a fre- 
quent site for the lodgement of foreign bodies. 

Pathology. — The pathological alteration in the lingual tonsil 
does not differ from the simple acute or chronic catarrhal inflam- 
mation described in the chapter on General Considerations (page 
62). The gland-structure is swollen and edematous, and stands 
up as large prominences which can be seen macroscopically, either 
directly or by the aid of the laryngoscope. The involvement of 
the lingual tonsil frequently follows inflammatory conditions of 
the adjacent and surrounding structures. 

Symptoms. — There is excessive secretion with a constant ten- 
dency to clear the throat, and, while such effort frees the membrane 
from secretion, there remains the sensation as of the presence of 
some foreign material in the pharynx. On swallowing there is 
the feeling, as often expressed by patients, as if they " swallowed 
over something." In the use of the voice the patient soon com- 
plains of throat-ache, with a certain amount of hoarseness, which 
is due to the hypersecretion and the associated inflammatory con- 
dition about the larynx, sometimes involving the vestibule. These 
symptoms are aggravated by eating. There may be slight cough 
besides. The sense of taste, usually only impaired, in some chronic 
cases may be entirely lost. There may be slight enlargement of 
the sublingual glands as well as those at the angle of the jaw. 

Where there is a general catarrhal condition involving the 
entire nasopharyngeal structure, with relaxed elongated uvula, it 



ACUTE PHLEGMONOUS INFLAMMATION. 515 

is well to remember that while the parts are relaxed this elongated 
uvula may come in contact with the epiglottis or lingual tonsil 
and be the cause of constant tickling and hacking cough. 

Diagnosis. — The diagnosis can be easily made by the aid of 
the laryngoscopic mirror, which will show the prominent elevations 
at the base of the tongue, with the accumulated secretion. 

Prognosis. — Under proper treatment the prognosis is good. 
Rarely ever does the condition progress to such permanent patho- 
logical alterations as to render the gland-structure not amenable 
to treatment. 

Treatment. — The treatment should be directed toward the 
correction of the underlying causative factor, whether it is a purely 
local lesion or whether it is a local lesion dependent upon some 
constitutional or remote condition. In any case the lingual tonsil 
should always be examined when there is inflammatory disease of 
the throat. Irregularities in the intestinal tract should be cor- 
rected and constitutional dyscrasise relieved by alterative and 
tonic treatment. Inflammation of the lingual tonsil is frequently 
confused with pharyngitis or lesions of the faucial tonsil, and 
often the whole treatment is directed toward these structures, 
with entire neglect of the area really diseased. For the local 
treatment, astringents are the most efficacious. They should 
be preceded, however, by gentle purgation. An admirable 
astringent gargle is alum 8 grains and tannic acid 4 grains 
to the ounce. This should be used, preferably after each meal, 
diluted with an equal amount of water. As a local applica- 
tion by means of the curved applicator and a pledget of cotton, 
there should be used such astringents as sulphocarbolate of zinc, 
6 to 10 grains to the ounce, or a 2 to 5 per cent, chlorid-of-zinc 
solution, which should be applied every day until the symptoms 
are relieved, which will usually occur after the fourth or fifth 
application. Equally good results may be obtained by the appli- 
cation of compound tincture of benzoin with 50 per cent, boroglyc- 
erid, or by the application twice daily of tincture of iodin direct 
to the lingual tonsil. 

ACUTE PHLEGMONOUS INFLAMMATION. 

Acute phlegmonous inflammation may occur as a primary affec- 
tion, either in association with phlegmonous inflammation of 
adjacent structures or as the result of mechanical injury. The 
inflammation may involve a portion of the glandular masses ; but, 
as a rule, it involves the entire mass. 

Symptoms. — Besides the general febrile symptoms there is 
pain in the throat, especially localized in the region of the hyoid 
bone, on one or both sides. Deglutition is extremely difficult and 
painful, the attempt causing shooting pains in the ear. An effort 



516 DISEASES OF THE TONSILS. 

to protrude the tongue usually increases the pain, although no 
difficulty is experienced in opening the mouth. There is usually 
a marked increase in the flow of the saliva. In severe cases there 
may be threatened edema of the glottis. 

The diagnosis can easily be made by the use of the laryngo- 
scope and by digital examination. 

Treatment. — As the abscess forms rapidly, it is likely to 
rupture spontaneously ; but if recognized early, it should be 
immediately incised. 

HYPERPLASIA OF THE LINGUAL TONSIL. 

Hyperplasia of this gland-structure, while rare, may accompany 
chronic inflammatory processes of the pharynx. 

The Symptoms are very much the same as in acute inflamma- 
tion with absence of pain, while the sensation of a foreign body in 
the throat is reflected to the center or either side of the hyoid 
bone. The symptoms disappear during eating or drinking, but 
are increased by the use of the voice. 

The diagnosis can be easily made by the use of the laryn- 
goscope or by digital examination. 

Treatment. — For the reduction of this thickened tissue the 
best and the most effectual means is the galvanocautery, which, 
however, should be carefully used, and the cauterization should 
not be deep. Considerable reduction of the thickened tissue may 
be brought about by the direct application of dilute hydrochloric 
acid to the projecting masses, applied by means of cotton and 
probe. The cotton should be wrapped tightly on the end of a 
fine-pointed probe, and after saturating it with the acid, any excess 
should be removed by applying a bit of absorbent cotton to the 
saturated pledget ; this will prevent the acid spreading over healthy 
tissue. The application should be repeated not oftener than every 
fourth day. Twenty per cent, chromic acid or 3 per cent, chlorid 
of zinc applied in the same way is equally beneficial. 

MYCOSIS OF THE LINGUAL TONSIL. 

This is an inflammatory condition brought about by the local 
infection with the Leptothrix buccalis. Under the tonsil small 
yellowish projections appear, resembling mold. As a rule, slight, 
if any, ulceration occurs, it being more of a superficial desquamation 
of the outer layer of the epithelium. 

Treatment. — The condition should be treated by antiseptic 
mouth-washes and careful attention should be directed to the in- 
testinal tract ; the local areas should be touched with a 6 per cent, 
solution of chlorid of zinc, or, what is still better, pure iodin. A 
2 per cent, formalin solution in some cases is just as efficacious, 
although at times the condition is very obstinate, and resort to the 
galvano-cautery may be necessary. 



LARYNGEAL TOSSIL. 517 



VARICES. 

The veins at the base of the tongue may be uniformly dilated 
and show as bluish tortuous cords. Occasionally they are mark- 
edly irregular, showing saccular dilatations which appear above 
the surface, and which may rupture and cause severe hemorrhage. 
This vasomotor neurosis in females often accompanies menstrual 
disorders. It is especially likely to occur during pregnancy or 
the menopause. It may also be the result of alcoholism. These 
enlarged veins may produce peculiar subjective sensations, the 
most common of which is a peculiar sensation such as would 
follow a moving body in the throat. 

Treatment. — The condition is usually dependent upon some 
interference with venous circulation, and is often seen along with 
intestinal lesions, or lesions of the heart, kidney, or liver. Treat- 
ment should first be directed toward the relief of these underlying 
causes. Should this fail to give relief, the dilated vessels should 
be punctured here and there by the galvanocautery. The rupture 
of these saccular dilated veins will account for the so-called idio- 
pathic hemorrhage occurring at the base of the tongue. The act 
of spitting blood is most alarming to the patient, and when such 
has occurred, in endeavoring to locate the site of hemorrhage, the 
dilated vessels at the base of the tongue should never be over- 
looked. 

As a point in differential diagnosis, in cases of hemorrhage from 
the dilated vessels at the base of the tongue there will be absolute 
absence of rales — in fact, no lung-symptoms. 

LARYNGEAL T0N5IL. 

Situated within the ventricle of the larynx, involving the 
mucosa, embedded within the meshwork of the fibrous connective 
tissue, are small areas of adenoid tissue, which are, in reality, 
aggregated lymph-follicles. Physiologically the structure cannot be 
demonstrated except by microscopical study. However, in inflam- 
matory conditions of the larynx, especially about the cords in the 
vestibule, these follicles become engorged, swollen, and edematous, 
and show as minute elevations. As such a condition is always 
associated with lesions of the larynx, it is sufficient merely to 
mention its presence. 



CHAPTEK XVIII. 
DISEASES OF THE PHARYNX 

Malformations and Deformities ; Stenosis. 

1. Dilatation (Pharyngocele). Diverticulum. 

Acute Inflammatory Diseases. 

1. Simple Acute Pharyngitis. 

2. Infective Pharyngitis. 

3. Membranous Pharyngitis. 

a. Croupous ; Simple Membranous. 

b. Diphtheritic. 

c. Streptococcic. 

d. Pneumococcic. 

4. Gangrenous Pharyngitis. 

5. Occupation Pharyngitis. 

6. Hemorrhagic Pharyngitis. 

7. Pharyngitis Glandulse Lateralis. 

8. The Pharynx in the Exanthemata and other Febrile Affections. 

a. Scarlet Fever. 
6. Small-pox. 

c. Measles. 

d. Erysipelas. 

e. Intermittent Fever. 
/. Gout. 

g. Typhus Fever. 
h. Typhoid Fever. 
i. Influenza. 
j. Varioloid. 
k. Chicken-pox. 

9. Ludwig's Angina. 

10. Vincent's Angina. 

11. Angina Ulcerosa Benigna. 

Chronic Inflammatory Diseases. _ 

1. Simple Chronic Pharyngitis. 

2. Subacute Pharyngitis. 

3. Follicular Pharyngitis. 

4. Hyperplastic Change in the Pharyngeal Structure. 

5. Atrophic Pharyngitis. 

6. Cyanotic Pharyngitis. 

7. Rheumatic Pharyngitis. 

a. Acute. 

b. Chronic. 

8. Angioneurotic Edema. 

9. Infectious Granulomata of the Pharynx and Nasopharynx. 

a. Tuberculosis. 
1 . Lupus. 
6. Syphilis. 

c. Glanders. 

d. Actinomycosis. 

Abscess, Retropharyngeal. 

Urticaria. 

Herpes. 

Ph ary ngomy cosis. 

518 



MALFORMATIONS AND DEFORMITIES OF PHARYNX. 519 

Non-inflammatory Diseases. 

1. Pulsating Arteries. 

2. Pharyngeal Aneurism. 

3. Anemia of the Pharynx. 

Ulcers. 

4. Neuroses of the Pharynx. 

a. Anesthesia. 

b. Hyperesthesia. 

c. Paresthesia. 

d. Neuralgia. 

e. Neuroses of Motion. 

1. Spasm. 

2. Paralysis. 

Foreign Bodies in the Pharynx. ' 

MALFORMATIONS AND DEFORMITIES OF THE PHARYNX. 

Of the malformations met with in the pharynx, one of the 
most important is stenosis, which may occur early, congenitally, 
or may be found as secondary to inflammation or injury within 
the cavity or the tissues of adjacent structures. 

A few cases of congenital atresia, either complete or partial, 
have been reported. Complete closure of the pharynx from birth 
is usually associated with pouches, and will be treated under that 
heading. 

Secondary stenosis of the pharynx may be due to cicatricial 
contraction, the result of specific inflammatory processes or of 
traumatism. Of the former class, the lesions consequent upon 
syphilis are the most common. Adhesion of the pharyngeal 
structure to adjacent tissue, or contraction due to specific lesion in 
the pharynx itself, is by no means an uncommon occurrence. It 
may be found high up in the pharyngeal cavity or in the laryngo- 
pharynx, and presents the peculiar stellate appearance characteris- 
tic of the syphilitic scar — the symptoms, of course, differing accord- 
ing to the location. The treatment is most unsatisfactory, and 
the amount of success will largely depend on the length of time 
that the stricture has existed, and the perseverance of both patient 
and surgeon. Antisyphilitic treatment should, of course, be insti- 
tuted at once ; the stenotic stricture should be split and dilated 
persistently by graduated bougies. The best method of incising 
the constricting tissue is with the galvanocaustic knife. 

Tubercular contractions are rare — practically unknoAvn — as 
tubercular ulceration does not tend to heal, and the majority are 
due, perhaps, to that modified form of tuberculosis known as 
lupus. Of the infective diseases which are most likely to be fol- 
lowed by septic inflammation, adhesion, and contraction, may be 
mentioned scarlet fever, diphtheria, small-pox, and erysipelas. 

Traumatic stenosis may occur at any age, and is usually the 
result of a scalding burn, or of the accidental or intentional swal- 
lowing of caustic liquids. As a rule, this form of trauma is rapidly 



520 DISEASES OF THE PHARYNX. 

fatal, because of the extent of the lesion and because the resultant 
inflammation is usually associated with edema of the glottis. 
While the treatment varies with each individual case, emollients 
should be used in all cases of burns, such as menthol 20 per cent, 
in either carbolized vaselin or plain liquid albolene. 

Spasmodic contraction of the pharynx is due in great part to 
the same cause that produces pouches — i. e., the bolting or hurried 
swallowing of food, or food improperly masticated. 

Extrinsic Stenosis. — Of the causes outside of the pharynx 
which are likely to produce narrowing of the structure, the chief 
is disease of the vertebral column. Early deformity, such as for- 
ward curvature of the spine, or the twisting of one of the verte- 
brae upon its axis, will produce a lessening of the pharyngeal 
cavity. 

Retropharyngeal abscess, independent of caries of the vertebrae, 
is another condition which may affect the size of the pharynx by 
encroaching upon its cavity. Enlargement of the apices of the 
lateral lobes of the thyroid gland may also, by pressure, result in 
inflammation, and cause choking sensations and other signs of 
respiratory disturbance. 

In Hodgkin's disease, if the cervical glands are involved, it 
may also tend to cause contraction in the size of the pharynx, and 
the same may occur in carcinomatosis. 

Diverticula, or dilatations of the pharynx, are seen either 
as a result of defective development during the fetal state, or 
are brought about by imperfect growth or mechanical distention. 
Congenital pouches are almost always associated with complete 
atresia of the pharynx or absence of the esophagus. The etiology 
of the condition is not well understood, but perhaps the congenital 
displacement of the right subclavian artery may have something to 
do with it. Pouches, or dilatations of the pharynx (pharyngocele), 
generally occur in the aged, although it is likely that they are 
often overlooked or their importance belittled for years. The 
customary cause of the condition is the ingestion of food improp- 
erly masticated because of unsound or defective teeth, or the swal- 
lowing or bolting of masses of food that cannot be handled by 
the constrictor muscles of the pharynx. The first symptom of the 
condition will usually be an inability to swallow, or pain on 
deglutition. Boluses of undigested food may be spontaneously 
ejected, without retching or vomiting, at varying intervals after 
eating. The pouch may be of such a size that the food collected 
within it may cause considerable distention, visible on the outside 
of the neck ; and the patient may be able, by pressure from with- 
out, to cause the food to enter the pharynx and subsequently the 
esophagus. The treatment of the condition depends largely upon 
the position and size of the pouch. Should the cavity of the 
diverticulum be sufficient to cause a tumor visible externally, a 
pad properly fitted to the neck may obviate the disturbance and 



SIMPLE ACUTE PHARYNGITIS. 521 

enable the patient to swallow without great difficulty. This plan 
failing, resort might be had to the galvanocautery, and the edges of 
the pharynx cauterized and brought together in an attempt to cause 
coalescence and contraction, or even the mouth of the cavity might 
be denuded of the mucous membrane and held together by stitches 
— a procedure difficult of performance and fraught with uncertain 
results. 

SIMPLE ACUTE PHARYNGITIS. 

Synonym. — Acute catarrhal pharyngitis. 

Definition. — An acute catarrhal inflammation of the pharyn- 
geal mucous membrane in which are hyperemia and congestion 
with slight submucous infiltration, as well as hypersecretion and 
hyperelaboration of mucus. 

Etiology. — Acute pharyngitis may be brought about purely 
by cold or exposure or may spring from inflammatory processes 
of the adjacent or contiguous structure — at least, catarrhal condi- 
tions in the nasopharynx and anterior nares are predisposing fac- 
tors. The same may be said of the gastric or intestinal disorders. 
"While they may not be direct factors, they are predisposing, 
inasmuch as the lowered vitality and local congestion due to 
venous stasis render the pharyngeal structure more susceptible. 
Epidemic influenza (la grippe) is a frequent cause. Constitutional 
diatheses are also important factors. Bad hygienic conditions, 
improper ventilation, insufficient clothing, through their vitiating 
effect on general health, are also causal factors. Persons whose 
occupations are of a sedentary character are especially liable to 
attacks of acute pharyngitis. Inflammatory conditions of the 
lingual tonsil frequently give rise to symptoms simulating pharyn- 
gitis. Alcoholic intemperance, the use of tobacco, and the over- 
indulgence in any stimulant, through their constitutional effects, 
also predispose. Age is not such an important factor, although 
it is especially common in the young and middle-aged. In 
children it is noticed as quite often due to intestinal irritation. 
The fact of taking cold can usually be explained by some 
of the above-mentioned predisposing elements. Those whose 
occupations expose them to irritating fumes, dust, hot air, or the 
discomforts of overcrowded rooms, or who are exposed to draughts 
or sudden changes of temperature, are especially liable to attacks 
of acute inflammation of the pharyngeal structures. Occasionally 
an acute pharyngitis may be the result of an acute process in 
adjacent structures, such as the tonsil, nose, or nasopharynx. 

Pathology. — The pathological alteration in the mucous mem- 
brane of the pharynx in acute catarrhal pharyngitis is the same as 
in acute catarrhal inflammation in any mucous membrane. It con- 
sists in hypersecretion and hyperelaboration of mucus with hyper- 
emia and congestion of the blood-vessels in the submucosa with sub- 



522 DISEASES OF THE PHARYNX. 

sequent pressure on the mucous glands situated in the membrane. 
Inflammatory exudate is poured out largely on the surface, which, 
mixed with the mucus and desquamated epithelial cells, gives it its 
peculiar whitish or grayish color. The amount of fibrin present will 
largely determine the tenacity of the secretion. The character of 
the secretion and the inflammatory exudation is also largely con- 
trolled by the general condition of the individual. Not only when 
there is any constitutional diathesis or generally bad nutrition is 
the character of the normal secretion altered, but when influenced 
by inflammatory processes the variation is more marked, as the 
chemical constituents of the blood in a great measure determine 
the character of the exudate. If the exciting cause of acute 
pharyngitis produces sudden congestion, rupture of the minute 
blood-vessels is liable to occur, and the secretion and exudation 
may be blood-stained. When the inflammatory process is very 
slight, the exudate will be more fluid in consistence, with very 
little tendency to accumulation. As a rule, the severer the inflam- 
matory condition, the more fibrinous and albuminous will be the 
exudate. This is due to the fact that the hyperemic and con- 
gested vessels of the submucosa block up the muciparous glands 
and prevent the elaboration of mucus. In the second stage, how- 
ever, with the pouring out 'of the liquor sanguinis the vascular 
pressure is relieved, and the surface is covered with the pent-up 
secretion and the inflammatory exudate. Occasionally this exu- 
date may be so highly fibrinous as practically to form a membrane 
which is neither infectious nor diphtheritic in character — in real- 
ity, a non-infectious membranous inflammation. 

A certain amount of inflammatory exudate within the sub- 
mucous connective tissue will give rise to slight edema. This 
edematous condition may extend to the surrounding structure, 
especially the uvula and soft palate. If the variety of inflamma- 
tion is purely catarrhal, and is not an acute exacerbation of a 
chronic condition, after the subsidence of the inflammatory phe- 
nomena the tissue will return to the normal. 

Symptoms. — The onset is usually sudden, the severity of the 
symptoms depending entirely on the suddenness of the attack. 
The color of the membrane varies from a bright pink to a livid 
red, and the surface may show distinctly outlined injected vessels, 
the congestion as well as the color gradually fading off into sur- 
rounding structure. The uvula, soft palate, and pillars of the 
fauces may be slightly translucent from edema. In the early stage 
the surface of the membrane will be shiny and smooth ; gradually, 
as it progresses into the second stage, it will become more rough- 
ened and granular. In the first stage the throat is dry, with 
small patches of dried mucus here and there. In the second 
stage the secretion and exudate are profuse, and at first of a 
watery consistency, gradually becoming more tenacious and muco- 



SIMPLE ACUTE PHARYNGITIS. 523 

purulent, and, if highly fibrinous, will tend to coagulate on the 
surface. The sufferer's constant effort to clear the throat of 
mucus is in itself a source of irritation. The pain is usually 
severe, although not unbearable, is decidedly irritating, and is 
increased by action of the pharyngeal muscles. There is a sen- 
sation of fulness or constriction of the throat, almost that of the 
presence of a foreign body, causing a constant desire to swallow. 
The pain may be reflected to the ear, or the acute pharyngitis 
may exist along with acute catarrhal inflammation of the naso- 
pharynx, which in itself would' cause pain in the ear. Owing 
to extension of the inflammatory process by continuity of struct- 
ure, there may be associated inflammation of the larynx. In 
fact, any of the adjacent structures may be involved. The im- 
pairment of hearing will depend entirely on the involvement of 
the nasopharyngeal structure. The pain is always increased by 
the act of swallowing, rendering it almost impossible for the 
patient to partake of solid nourishment. The sense of taste 
may be partially impaired, which is especially true if the lingual 
tonsil is involved. On account of the accumulated secretion and 
the irritation to the peripheral nerve-filaments, there is a constant 
tendency to hawk or cough. If associated with considerable 
laryngeal or bronchial irritation, the cough will be more severe 
and spasmodic in character. Occasionally the expectorated 
mucus will be blood-stained. Unless there is associated laryn- 
geal or nasal involvement, respiration is not interfered with. The 
voice is thick and husky and altered in pitch and tone, and, if 
at the same time there is laryngeal inflammation, it may be com- 
pletely lost. The constitutional or clinical phenomena are present 
in a degree proportionate to the severity of the local lesion. There 
is usually a slight rise of temperature with digestive disturbances, 
besides perverted secretion evinced by the constipation and the 
scanty, high-colored urine. The tongue is coated and the breath 
foul. Quite frequently the inflammation of the pharynx is only 
an associated condition or a local manifestation, as observed in 
epidemic influenza. In such cases the systemic phenomena will 
be more marked, although in the simple acute variety there may 
be pains in the muscles of the neck and joints in addition to an 
unbearable headache. 

Diagnosis. — Acute catarrhal pharyngitis cannot always be 
differentiated solely by the local condition from that accompany- 
ing the eruptive fevers, or a rheumatic or gouty diathesis, or that 
occurring in epidemic influenza or la grippe. The constitutional 
phenomena must also be taken into consideration. In children 
this is especially true, and the diagnosis should be guarded. 

Prognosis. — The prognosis is good, as the acute attack 
usually lasts from four to ten days, and when uncomplicated is not 
dangerous. 



524 



DISEASES OF THE PHARYNX. 



Treatment. — As the lesion may be d ue purely to a local irri- 
tation, or may be a local manifestation of some constitutional con- 
dition, or may accompany or result from the latter, the symptoms 
produced, regardless of cause, are very much the same, and plans 
of rational treatment are naturally based on the etiological factors, 
either primary or secondary. First, then, treatment for the imme- 
diate relief of the distressing symptoms ; and, second, the appro- 
priate treatment for such conditions, constitutional or local, which 
may give rise to attacks of acute pharyngitis. In the early dry 
stage, cold applied externally in the form of ice-water cloths or 
ice-pack is highly beneficial. Where there is no cardiac lesion, 
tincture of gelsemium may be administered in 1- to 5-drop doses 
every three hours. This will aid materially in lowering the vas- 
cular tone and will lessen the tendency to congestion. How- 
ever, it must be remembered that the drug is a powerful motor 
depressant, and its action should be carefully noted. For the 
relief of the dryness of the throat in the early stage, after the ice- 
packs have been discontinued, the throat should be gargled with 
hot water, or great relief can be obtained by the use of aqueous 
extract of hamamelis, cinnamon water, and peppermint water, in 
equal parts, as a gargle every hour. Should the attack be due to 
gastric or intestinal irritation, or to a gouty or rheumatic diathesis, 
the general treatment should be directed to the relief of the under- 
lying cause. If the lesion is associated with, or a continuation of, 
an acute inflammatory process of the postnasal cavity, the treat- 
ment should be directed more to the nasopharynx than to the 
pharynx proper. The administration of certain drugs, such as 
iodin, bromin, and phosphorus preparations that are eliminated 
by the mucous membrane, may be the cause of the inflammatory 
process. Their prompt withdrawal is usually the only treatment 
necessary. 

When the inflammation is limited to the pharynx — and by the 
pharynx is understood that portion of the wall that is visible on 
oral inspection — the remedial agents should and can be applied 
directly to the part. This can be done in a number of ways 
— by means of gargles, sprays, cotton and applicator, or in 
the form of lozenges. If the patient is seen in the early or 
first stage of the inflammatory process, the treatment indicated 
is vastly different from that demanded when it has reached the 
second or exudative stage. It must be remembered that in 
the first stage the pathological alteration is not a structural 
one, but is entirely limited to the vessels ; that the mucous 
membrane has its normal lubricating secretion, which is fur- 
nished by the mucous glands located in the submucosa ; that in 
the first stage, or stage of engorgement, the pressure exerted 
by the now overdistended arterioles and capillaries cuts off 
this normal secretion by the temporary occlusion of the excre- 



SIMPLE ACUTE PHARYNGITIS. 525 

tory ducts, and therefore the surface will be dry and irritated. 
The object of treatment in this stage should be depletion and the 
rapid relief of the vascular engorgement. The local or constitu- 
tional application of such agents as cause relaxation of tissue will 
bring about depletion, if not more rapidly, at least more in accord- 
ance with nature's process, than by the application of astrin- 
gents or remedies which contract the tissue. While it is possible to 
relieve the engorgement and cause contraction of the vessels, and 
even re-establish circulation and secretion in local spots of inflam- 
mation, yet the irritation produced by the application of such 
remedial agents to the delicate mucous-membrane surface may 
augment the very condition you are aiming to relieve. Instead, 
then, of the application of such solutions as iodin, nitrate of sil- 
ver, etc., there should be administered internally and locally such 
drugs as pilocarpin, apomorphin, ipecac, tartrate of antimony, and 
other drugs of the same nature. These should be administered 
in small and frequent doses. An effervescing tablet containing jfa 
of a grain of pilocarpin, allowed to dissolve slowly in the mouth and 
repeated every hour for three or four doses, will usually give relief. 
The administration of drugs which act on the vasomotor sys- 
tem, causing contraction of the vessel-wall, may give the desired 
result, and is preferable to the local application of any irritating 
agent. If the inflammatory process be localized, astringents may 
be used with good results ; but if the process involves the entire 
pharyngeal surface, they should not be used. If the throat is 
irritable, or there is present the raw feeling of which the patient 
so frequently complains, local sedatives should be used. The parts 
should be sprayed with a bland oil containing 3 drops each of oil 
of sandal-wood and oil of sassafras to the ounce, the oil of sandal- 
wood being decidedly sedative to the mucous membrane and the 
bland oil serving the double purpose of a lubricant and a protector. 
To some patients the oily preparations are decidedly disagreeable ; 
in such cases the surface may be sprayed with a weak hydrochloric- 
acid solution, not stronger than 5 to 10 drops of the dilute acid to 
the ounce of water, the object being more to relieve the irritation 
than to cause contraction of the vessels. When menthol is used 
for the relief of this condition, it should not exceed 2 grains to the 
ounce. If used in combination with camphor, much better results 
are obtained. The following usually gives relief : 

ly. Camphorse, gr. ij (0.12) ; 

Menthol (crystal), gr. ij (0.12) ; 

Olei santali, gtt. iv (0.24) ; 

Alboleni (liquid), fl^j (30.0).— M. 

It is rarely necessary to administer drugs internally for the 
relief of this irritation. Should the severity of the symptoms 



526 DISEASES OF THE PHARYNX. 

demand internal medication, we have in codein in small doses 
the best remedial agent. When the pharyngitis is not dependent 
upon purely local conditions, but is caused by gastro-intestinal or 
hepatic disturbances, immediate attention should be given to the 
gastro-intestinal tract. A purgative should be given, followed by 
a saline ; such as the administration of 1 to 3 grains of calomel to 
1 grain of compound colocynth powder, followed by a saline that 
will stimulate glandular secretion. This can be accomplished 
by the administration of the granular effervescing phosphate of 
sodium, 2 to 4 drams, which may be repeated three times daily. 
The succinate of soda in 5- to 20-grain doses is equally efficacious. 
In the second or exudative stage, where the vessels and glands 
have relieved themselves of engorgement, very little medication 
is required. If the secretions are profuse and tenacious, the mem- 
brane should be cleansed with a simple alkaline wash. If the 
inflammation is localized, due to any of the above causes, and 
does not involve the entire pharyngeal surface, astringents may be 
used. Such solutions as alum, 4 to 8 grains, with 4 to 8 grains of 
tannic acid to the ounce, or chlorate of potassium, 10 to 15 grains 
to the ounce, should be applied by means of sprays, or, better, by 
means of cotton and an applicator. When the inflammation is 
localized to the margins of the pharyngeal wall, which is often the 
case if the disease is dependent upon gastro-intestinal irritation, 
relief can be obtained by the use of a mild astringent, such as 
the compound tincture of benzoin, with equal parts of a 50 per 
cent, boroglycerid. Should the second stage not pass rapidly on 
to resolution, the hypersecretion and elaboration of mucus can be 
controlled by the administration of minute doses of belladonna in 
the form of atropin, or aconite in the form of aconitin — of either, 
the t ^-q to g-J-g- of a grain — not repeated oftener than every three 
or four hours, and only to the point of beginning physiological 
effects. These drugs apparently have a specific action on the 
faucial circulation. 



INFECTIVE PHARYNGITIS. 

Synonyms. — Ulcerative sore throat; Hospital sore throat; 
Phlegmonous pharyngitis ; Suppurative pharyngitis ; Streptococcal 
pharyngitis. 

Definition. — Superficial ulceration of the mucous membrane 
of the pharynx, due to infection. It is frequently epidemic. 

Ktiology. — There is often seen in individuals exposed to the 
influence of septic poisons an attack of acute infectious inflamma- 
tion of the pharyngeal mucous membrane. Some people are more 
susceptible than others. The condition is quite frequently seen by 
physicians during epidemics of diphtheria or scarlet fever, and 
sometimes occurs in surgeons when exposed to septic poisons. 



INFECTIVE PHARYNGITIS. 527 

There is usually some lessening of physiological resistance on the 
part of the mucous membrane lining the pharynx, brought about 
either by constitutional diatheses or pre-existing local inflamma- 
tory processes, rendering the individual more susceptible. Nurses 
and hospital attendants are frequently attacked. A somewhat 
similar condition has also been observed in students who are 
working in the dissecting room. The usual bacteritic infection is 
the streptococcic, although associated with it are always staphylo- 
cocci. Occasionally the pseudobacillus of diphtheria is also pres- 
ent, but not as a direct etiological factor. 

Pathology. — While ulceration of the pharyngeal mucous 
membrane may occur in almost any of the inflammatory processes, 
yet it is most likely to take place when such processes are of an 
infectious nature. In this ulcerative variety the epithelial cells 
on the surface are attacked by the pathogenic bacteria and undergo 
liquefaction-necrosis, with invasion of the bacteria into the deeper 
structure, where, from the local cutting off of the blood-supply, owing 
to the inflammatory processes, together with the rapid liquefac- 
tion-necrosis brought about by the infection, there soon form minute 
ulcers extending through the basement membrane. However, 
in many cases the process is not distinctly ulcerative, but one of 
desquamation, the localized spots of liquefaction-necrosis not 
involving the basement membrane. Occasionally the infection 
may localize beneath the mucous membrane and produce abscess- 
formation, or the superficial structures by the local infection may 
secrete or manufacture pus and produce a granular appearance, 
which resembles, and in reality is, a pyogenic membrane, thus 
giving rise to the suppurative variety. AYhen small abscess-for- 
mation occurs in the submucosa, it is likely to become diffused 
and give rise to the diffused suppurative pharyngitis — peripharyn- 
geal phlegmon. From all the varieties of infection excepting 
diphtheria the process differs only in degree. 

Symptoms. — The earliest symptom will be extreme sensi- 
tiveness of the throat, especially on swallowing. Gradually the 
throat feels dry, swollen, and rigid. Reflected pain will be felt in 
the ear and the muscles of the neck, frequently extending down 
to the muscles of the pharynx. There is a slight rise of tempera- 
ture, and the patient feels restless and depressed. Secretions are 
deficient, the tongue is heavily coated and furred, and the breath 
very offensive. There is generally considerable frontal headache 
and mental hebetude. The ulcers are usually located on the 
lateral pharyngeal walls, and quite frequently on the tonsil and 
soft palate. One special site of location is just behind the pillars 
of the fauces, which can be seen only when the pharyngeal struct- 
ure is in a relaxed position. The ulcer is usually very small 
in size, and is coated with shaggy membrane which is formed 
by liquefaction- and coagulation-necrosis. This, however, varies 



528 DISEASES OF THE PHARYNX. 

in appearance, as often the material is sloughed away and leaves 
a perfectly clear ulcer. 

Diagnosis. — From the accompanying history, together with 
the rapid development and associated bacteriological examination, 
the diagnosis can easily be made. 

Prognosis. — Prognosis is, as a rule, favorable, although septi- 
cemia may result. 

Treatment. — The patient should be placed in as hygienic 
surroundings as is possible. The bowels should be freely purged 
and minute doses of calomel and bicarbonate of soda continued. 
Internal administration of tincture of chlorid of iron in from 10- to 
30-drop doses every two hours will be of great service in com- 
bating any tendency to septicemia. The throat should be fre- 
quently cleansed, first with an alkaline gargle used as warm as can 
be comfortably borne by the patient. The ulcerated areas should 
be touched with a 3 per cent, chlorid-of-zinc solution, or dilute 
nitric acid, 20 drops to the ounce of water. Considerable relief to 
the sufferer may be afforded by the use of Mackenzie's carbolic- 
acid throat-tablets (B. P.), allowing the patient to dissolve a tablet 
slowly in the mouth every one or two hours. If the membrane is 
quite adherent and thick, Loeffler's solution should be applied by 
means of a cotton pledget wrapped tightly on the applicator, being 
careful not to have any excess of the solution on the cotton, so that 
its application can be limited to the membranous areas. If the ulcers 
are very painful, relief can be afforded by the local application of an 
oily solution such as benzoinol, to which has been added 4 grains of 
menthol, 4 drops of sandalwood oil, and 2 drops of oil of eucalyp- 
tus to each ounce. This can be applied every few hours. Ortho- 
form is equally good for the relief of the pain. Heated vapors 
afford temporary relief. Cold should only be used very early 
in the process, and may do much to arrest its progress. The 
patient should be instructed to wrap an ice-water cloth around 
the neck, enveloping that in a dry towel, and also allowing 
small particles of ice to be dissolved in the mouth. However, if 
the condition is advanced in the inflammatory stage or has gone 
on to necrosis, hot applications are indicated rather than cold. 
After the relief of the acute symptoms the patient's general con- 
dition should be improved by the administration of tonics. 

Lactic Bacteriotherapy in Pharyngeal Affections. — In the last 
few years considerable attention has been called to the effect of 
bacteriotherapy in mucous membrane affections. Sufficient data 
has not been obtained to determine the efficacy of this remedy. 
However, in certain conditions it seems beneficial ; in conditions 
in which there is offensive breath, as associated with certain forms 
of rhinitis, nasopharyngitis, and pharyngitis, good results have 
been obtained. However, it is only in conjunction with local and 
systemic treatment (in other words, the removal of the cause) that 



MEMBRANOUS PHARYNGITIS. 529 

a cure is effected. The theory is that the lactic-acid bacteria mul- 
tiply rapidly and counteract the effect of the disease-producing 
bacteria, as well as the fungous forms of growth. 

MEMBRANOUS PHARYNGITIS. 
Varieties. — a. Croupous ; simple membranous; b. Diphtheria. 

Ceoupous. 

Often the practitioner will observe an inflammation of the 
pharynx that is in no wise diphtheritic, and while there is no 
question but that the condition is an infectious one, yet the infec- 
tion is not due to any specific bacteria or special germ, though the 
Streptococcus pyogenes is present to such an extent as to give rise 
to the term streptococcal infection. It is the same condition de- 
scribed by some writers as erysipelas of the throat. The clinical 
phenomena are almost identical with diphtheria, although of not 
such a grave character and of much shorter duration. The affec- 
tion is frequently seen in laboratory workers and persons exposed 
to infectious processes. Although somewhat resembling the ulcer- 
ative variety, in the pure membranous sore throat there is neither 
ulceration nor involvement of the basement membrane. The 
condition is, in reality, an acute infectious process in which there 
forms on the mucous-membrane surface a highly coagulable albu- 
minoid material which constitutes a false membrane and occurs 
along with desquamation of the superficial epithelium. On strip- 
ping off the membrane no ulcer is found, and, if any bleeding does 
occur, it is from capillary oozing. The question of infection and 
contagion is one which has been discussed by the profession from 
every standpoint ; and while the general consensus of opinion, con- 
firmed by clinical observation, proves that many of these cases are 
not infectious or contagious, at the same time the early clinical 
phenomena are so nearly identical with those of diphtheria that 
until the diagnosis is clearly established the precaution of isolation 
should be taken. 

Diagnosis. — The diagnosis is established by bacteriological 
examination and associated clinical phenomena. 

Treatment. — The treatment should consist in thoroughly 
cleansing and removing the membrane by first using an alkaline 
solution, followed by a solution of hydrogen peroxid (15 volume), 
aqueous extract of hamamelis, and cinnamon water, in equal parts. 
After the thorough cleansing and drying of the membrane, there 
should be carefully applied, by means of cotton tightly wrapped 
on the applicator, great care being taken to remove any excess 
of the fluid, Loffler's solution : 

fy. Toluol, 36 parts; 

Alcoholis absoluti, 60 " 
Liquoris ferri sesquichloridi, 4 " 

34 



530 DISEASES OF THE PHARYNX. 

While this is especially adapted to the treatment of diphtheria, vet 
in any infectious process its highly disinfecting properties are 
decidedly advantageous. Attention to general health and thorough 
cleansing of the intestinal tract are of importance. After the use 
of Loffler's solution the throat should be painted with compound 
tincture of benzoin and 50 per cent, boroglycerid, in equal parts ; 
or, if the pain is severe, there may be used instead — 

^. Camphora?, gr.j(.06); 

Menthol, gr.iv(.24); 

Alboleni (liquid), fl^ (30.).— M. 

To relieve the congestion and stimulate circulation a spray or 
gargle of hot water is highly beneficial. When the congestion is 
quite marked and the membrane tends to re-form, repetition of 
the application of Loffler's solution will be found necessary. As 
soon as the membrane ceases to form, the use of this solution 
should be discontinued. Equally good results may be obtained by 
the local application of pure guaiacol, observing the same pre- 
cautions as in the use of Loffler's solution. 

Diphtheria. 

Definition. — Diphtheria is an infectious disease, primarily 
locally manifested by a fibrinous exudate, followed by general 
systemic toxic involvement. The specific cause of the disease is 
the Klebs-Loffler bacillus, and the systemic symptoms and sequels 
are due to the toxins generated by this bacterium and its associ- 
ates. 

Synonyms. — Putrid sore throat ; Diphtheritis ; Angina diph- 
theritica ; Angina membranosa. 

History. — From D'Hanvantare — an Indian physician, a con- 
temporary of Pythagoras — there has been described an affection 
of the throat which may be interpreted as diphtheria. It would 
be impossible to give in detail the views of the various authors on 
the subject without devoting too much space to it, and for further 
information on the history of diphtheria the student is referred to 
the writings of Samuel Bard (1770) ; Bretonneau (1823-1855) 
Deslandes (1827); Fuchs (1828); Headlam Greenhow (I860) 
Jacobi (1877); Kauchfuss (1878); Morell Mackenzie (1879) 
Ruault (1892), and Lennox Browne (1895). 

Etiology. — For the production of diphtheria two factors are 
necessary : 1, The introduction of the specific germ, and 2, a suit- 
able soil for its growth. 

The human organism may be rendered susceptible to the inva- 
sion of the Bacillus diphtherias by variations from the normal in 
the oral cavity or its continuation, due to purely local causes or 



MEMBRANOUS PHARYNGITIS. 531 

due to a systemic involvement evidencing itself locally in altera- 
tion of the upper respiratory tract. Again, an economy below par, 
from whatever cause, is more prone to the disease, ceteris paribus, 
than a perfectly healthy organism. 

The factors predisposing and preparing a nidus of infection we 
shall divide, then, into heal and constitutional. 

Local Causes Predisposing" to Infection. — Enlargement 
of the faucial tonsil, overgrowth of Luschka's tonsil, carious 
and badly kept teeth, nasopharyngeal catarrh, and any dis- 
eased condition of the mucous membrane of the mouth render 
an individual, especially in childhood, liable to infection. Tonsil- 
lar enlargement, causing mouth-breathing with its attendant lower- 
ing of vitality and resisting power, tends to decrease about puberty, 
which might account for the fact that the maximum death-rate as 
well as the largest percentage of cases seem to be concurrent with 
that epoch. 

Another classification of the so-called predisposing causes is, 
first, into the factors increasing the virulence of the specific germ, 
and, secondly, into the circumstances which increase individual 
susceptibility. 

Any of the exanthemata — scarlet fever, measles, chicken-pox, 
etc. — or, in fact, any disease lowering bodily resistance or affect- 
ing the throat, acts as a predisposing cause by preparing an easy 
mode of entrance for the germ or favoring its development. 

Improper drainage, poor sewage, and unsanitary surroundings 
act as predisposing factors by causing an ordinary sore throat, 
which affords an inviting and fertile soil for the growth and prop- 
agation of the infecting agent. During an epidemic all classes 
are attacked alike, irrespective of social position. Children are 
the victims in far greater proportion than adults, the majority of 
cases occurring between the third and the fifteenth year. The 
infective principle is disseminated by the saliva, in the secretions 
from the patient, and by contact with the patient. It is highly 
tenacious and may persist indefinitely. Sporadic cases or infection 
that cannot be accounted for by actual contact with the disease 
may be due to the entrance of the germ from books, articles of 
clothing, etc., which harbor it in dried form until it revives and 
infects under favoring circumstances. 

Diphtheria is more prevalent in the cold, damp weather, irre- 
spective of the time of year — due, probably, to the greater number 
of ordinary throat-affections occurring at that time. 

Specific Cause of Diphtheria. — In 1875, at a congress held 
at AViesbaden, Klebs of Zurich announced the detection of the 
cause of diphtheria. It was not until 1883, however, that the 
discovery was given prominence. Loftier in 1884 isolated the 
germ, produced the disease in animals with the pure cultures, 
re-isolated the germ, but failed to produce paralysis. It remained 



532 DISEASES OF THE PHARYNX. 

for Roux and Yersin to succeed in 1888 in producing the disease 
as well as the paralysis, which furnished conclusive proof of the 
pathogenesis of the bacillus of diphtheria. If a platinum needle 
or a cotton swab be passed over the suspected membrane and 
cover-slips prepared, microscopical examination will show, if the 
exudate be diphtheritic, a great variety of organisms ; but chief 
among them will be noticed slightly curved bacilli of irregular 
size and outline ; there will be noticed a clubbing at one or both 
ends, and at times they will appear segmented, spindle in shape, or 
as curved wedges. Irregularity in outline is a marked character- 
istic of the Bacillus diphtherial. If Lomer's alkaline methylene- 
blue stain be used, many of those irregular rods will show clearly 
denned points in their protoplasm stained deeply, almost black. 
Morphology alone, however, will not establish the identity of these 
bacteria, but their cultural peculiarities as well as their pathogenic 
activity when introduced into the tissue of a susceptible animal 
have to be taken into consideration. Associated with the Bacillus 
diphtherial, and accredited with causing much of the confusion that 
exists between the clinical and the bacteriological diagnosis of 
diphtheria, there are found a number of other bacteria — e. g., 
streptococci, diplococci, staphylococci, "Brisou" coccus, and 
others. 

Much has been said and written for and against the identity of 
the germ of Von Hoffmann (the non-virulent bacillus) with that 
discovered by Lomer. Morphologically they are identical, differ- 
ing only in their pathogenic properties. We have concluded that 
the germs are the same, the difference in clinical symptoms and 
sequels depending on the amount and character of inoculation, 
together with the individual's power of resistance, modified by 
his environment. The difference in severity of epidemics is a 
well-known fact that can be explained as above. To the direct 
action of the bacilli of diphtheria is the membrane due ; their 
systemic effects are produced by their soluble products. The 
paralysis, the albuminuria, and other systemic evidences are due to 
the toxins of the specific germs ; while to the products of its 
associates — the streptococci and other pus-organisms — the phleg- 
mon, suppuration, and aspirative manifestations can be ascribed. 

The accompanying illustrations will give a good idea of the 
variation in appearance of the Bacillus diphtheria? (Fig. 210) after 
the use of serum-therapy, their appearance in a case treated with- 
out the use of the antitoxin (Fig. 211), and the change in appear- 
ance they undergo while developing on culture-media (Fig. 212). 

Pathology. — Pathologists and clinicians differ as to the 
pathological alterations in diphtheria ; this is largely due to the 
irregularities in the etiological factors. Irrespective of cause, we 
have to deal with two distinct varieties of this membrane-inflam- 
mation. That when the disease is due to a specific infecting agent, 



MEMBRANOUS PHARYNGITIS. 533 

as the bacillus of diphtheria, the membrane forms on the surface, 
as in any membranous condition ; but on its removal there will be 
bleeding, which is due to destruction of tissue or ulceration, and on 
microscopical examination this ulceration will be found to extend 

%*%& £§^ {wht/j 

'<p^i *&<& %zS& 

'-?*> \?ji\y- ^<^ 

Fig. 210. Fig. 211. Fig. 212. 

Fig. 210.— Tube inoculated forty hours after serum-injection. 

Fig. 211.— Tube inoculated forty hours after admission. The diphtheria bacilli are 
smaller and more regular in form than the preceding. 

Fig. 212. — Tube inoculated from growth forty-eight hours old. Irregular staves, stain- 
ing, for the most part, very unevenly. The bacilli seem to tend to the formation of short 
chains. Few ovoidal bodies are present. 

through the basement membrane, or that the nutrition which 
necessarily comes from the submucosa must be cut off'; the area 
beyond, being dependent on these vessels for nutrition, undergoes 
infective coagulative necrosis with sloughing. In some cases of 
diphtheria where the visible membrane is slight, the constitutional 
symptoms are marked and paralyses are produced, and there may 
be, low down in the air-passage, this ulceration. 

We do have a variety of membranous or fibrinous inflammation 
occurring on mucous membrane, in which there are no specific 
micro-organisms and in which there is no ulceration ; the mem- 
brane can be easily stripped off and does not bleed ; or if it is 
adherent and does bleed, it is due to the plastic material partially 
organizing on the surface. If it does bleed when stripped off, it 
is due to the capillary budding having taken place in the attempt 
at organization. 

Symptoms. — The period of incubation of diphtheria, if ex- 
perimentally produced, varies from twelve hours to three davs. 
Ordinarily the period between the exposure to the contagion and 
the appearance of false membrane is from two to four davs, occa- 
sionally reaching seven days. The onset of the disease is usuallv 
sudden in infants and very young children. The reverse holds 
good with older children and adults. 

Rarely is the disease ushered in with a chill. As a rule, there 
is a general feeling of depression, followed by headache, nausea, 
pain in the back and limbs, accompanying the throat-symptoms. 
Vomiting occurs at times. The bowels may be constipated or 
loose. Stiffness of the neck is complained of and pain at the 
angle of the jaw, not so markedly increased on attempting to open 
the mouth as in tonsillitis. The voice may lose its normal tone 
and become hoarse even before laryngeal involvement. There is 
nothing characteristic to be noted about the tongue, except that it 



534 DISEASES OF THE PHARYNX, 

is not so deeply furred and befouled as in tonsillitis. In the ordi- 
nary case of diphtheria the breath is not markedly affected, but in 
the severer instances of the disease it may become exceedingly 
offensive and characteristic. The child becomes listless, peevish, 
and does not play as is its wont. During the attack in children 
there will often be noticed a particularly characteristic pallor and 
waxiness of the complexion, with a pinching of the nostrils. An 
evanescent erythematous eruption, which may confuse the diagno- 
sis, occasionally is noticed on the trunk. 

The temperature in diphtheria uncomplicated by nephritis, 
otitis, adenitis, bronchopneumonia, paralysis, or cardiac involve- 
ment is disproportionate to the other systemic manifestations of 
the disease and rarely exceeds 101°— 103° F. A rise of tempera- 
ture to a point beyond that usually registered suggests extension 
of the membrane or complications, and should be a signal for 
increased watchfulness on the part of the attendant. 

The pulse of diphtheria is usually rapid in the extreme, and a 
sudden and decided slowing in the rate is to be looked upon as an 
omen portending ill, because the pulse-rate shows the extent to 
which the diphtheritic poison has involved the cardiac centers, the 
vagus, or the heart-muscle itself. 

The whole chain of cervical glands, usually attacked early by 
the infection, becomes tender and easily felt. It is to be borne in 
mind that children or even adults may have had enlarged cervical 
glands before the attack of diphtheria, and this possibility should 
be eliminated before attaching too much weight to this symptom. 
In severe and complicated cases the parotid and submaxillary 
glands may be implicated, and may go on to the formation of 
abscess. 

Strict attention should be paid to the amount and character of 
the urine voided. As a rule, albuminuria, which occurs in about 
33 per cent, of cases, is noticed early in the attack, due to toxic 
action on the kidneys. There is an excess of urea, and epithelial 
casts and cells are found in some cases. Hematuria is compara- 
tively rare. 

Inspection of the mouth early in the disease shows, as a rule, 
the tonsils and fauces red, swollen, and thickened. Soon patches 
of exudation are noticed extending rapidly, growing thicker, and 
becoming tough and tenacious. 

Situation. — The membrane of diphtheria may be situated on 
any part of the mucous tracts of the body or at mucocutaneous 
junction. A special predilection for the tonsils, however, is dis- 
played by the germ as a site of the necrotic process, which may 
extend thence in any direction. This is due to the situation of 
these structures and to their affording in their crypts an undis- 
turbed and favorable point for lodgement and development of the 
special bacteria. Virchow has aptly termed them " open wounds." 



MEMBRANOUS PHARYNGITIS. 535 

The pillars of the fauces and the uvula seem to be favorite 
routes of extension from the tonsils. The larynx may be prima- 
rily involved, or secondarily by extension from above. The nose 
is rarely the seat of the membrane other than by secondary involve- 
ment. Into the nasopharynx and through the Eustachian tubes, 
involving the hard or soft palate, covering the gingival or buccal 
mucous membrane, extending down into the esophagus or trachea, 
through the tear-duct to the conjunctiva, and into the antra — 
there is no part of the oral cavity or its continuations exempt from 
pre-emption primarily or by extension by the membrane. 

Consistency. — The consistency of the membrane varies in differ- 
ent stages of the disease. Early in the course of the disease it is 
tough, firm, and difficult of detachment, and leaves an abraded 
bleeding surface behind it. Later it is soft, shreddy, and more 
easily detached. The membrane sometimes appears as though 
" plastered " on the surface. The center is often thinner than the 
edges, which wrinkle before they separate. 

Color. — In a typical case of diphtheria the deposit is at first 
bluish-white, becoming more white and opaque or a pale lemon 
tint, merging into a yellowish or greenish-gray, and may finally 
become brown, and sometimes almost black, due to extravasation 
of blood. Rarely in lacunar diphtheria is the exudation seen as 
discrete yellow spots, finally coalescing. 

Nasal Diphtheria. — Acute. — When the nose is affected either 
primarily or by extension, a serous or serosanguineous discharge is 
an early symptom. This discharge is very irritating to the skin 
of the nasal orifice and upper lip, producing redness and excoria- 
tion, and, at times, formation of the false membrane may occur at 
these points. Epistaxis often takes place, and a peculiarly dis- 
agreeable and characteristic odor, due to the pent-up secretions, is 
noticed. It has been observed that in cases in which the membrane 
was primarily situated within the nose, there was not the same 
tendency to spread into the nasopharynx as from other situations. 

Chronic. — On record are well-authenticated cases of the for- 
mation of a false membrane in the nose, due to the Bacillus 
diphtheria?, but unattended by toxemia. A feeling of fulness in 
the head and a disinclination to mental effort were the chief sub- 
jective symptoms. Occlusion of the nostrils by a grayish-white, 
tenacious membrane lining the nasal chambers was revealed on 
inspection. Removal of this pellicle left a bleeding and abraded 
surface, soon covered by the re-formation of the membranous 
investment. The condition persisted for months despite treat- 
ment. 

It is our belief that in this case and others like it the mem- 
brane is not due to the influence of the bacillus, but can be classed 
under the fibrinoplastic form, and that the Klebs-Loffler bacilli 
are coincident rather than causal. This is illustrated in the cases 
mentioned on page 100. 



536 DISEASES OF THE PHARYNX. 

Diagnosis. — The early differentiation between diphtheria in 
a mild form and acute tonsillitis by the clinical symptoms is a 
difficult matter in many cases. There are forms, too, of mem- 
branous inflammation affecting the throat due to other organisms, 
especially the streptococcus, that confuse the diagnostician. Bac- 
teriological investigation, of course, will determine the presence or 
absence of the Bacillus diphtherise; but the finding of the Klebs- 
Loffler bacillus in the laboratory, and the consequent dictum by 
the bacteriologist that the case in question is " undoubtedly one of 
true diphtheria," often does not satisfy the clinician, who has seen 
the case apparently recovered from any symptoms whatever before 
the bacteriological diagnosis has been finished. As " one swallow 
does not make summer," so the finding of a few Klebs-Loffler 
bacilli does not prove that a given case is a disease consisting of a 
complexus of symptoms clinically recognized as diphtheria. 

It has been proved that the Klebs-Loffler bacilli exist in the 
throat without causing any appreciable reaction. I found them in 
my own throat, without experiencing any discomfort whatsoever, 
while making some researches in the antitoxin treatment at the 
Municipal Hospital, Philadelphia, early in 1895. 

There is no attempt in these statements to cast discredit on the 
bacteriologist's findings, but merely to bring out the fact that 
another factor enters into the establishment of clinical diphtheria 
beyond the mere presence of the specific bacillus. This may be 
either the susceptibility of the patient or the virulence of the 
inoculation. On these factors, together with the finding of the 
germ, depends the actual portrayal of a case of true diphtheria. 
Animal inoculation is the only method of determining germ-viru- 
lence, and often the case has worked out its own diagnosis before 
this can be established. The finding of the Bacillus diphtherise in 
any case, however, should put the physician on his guard, and the 
case should be isolated until further bacteriological investigation be 
made ; because a case at first apparently controverting the labo- 
ratory diagnosis may later, either from re-inoculation or lowered 
resistance, develop true diphtheria, or may impart to others the 
contagion, which may find a suitable non-resisting economy and 
develop with the greatest virulence. 

In establishing a diagnosis of diphtheria, the procedure should 
be somewhat as follows : Remembering that diphtheria is far more 
apt to occur among children than adults with the same exposure 
to contagion, let that have its weight. Next, obtain carefully the 
number of members in the household and their " throat " history. 
Ascertain accurately whether the patient or any of the family have 
been exposed to diphtherial infection, directly or indirectly, or to 
any other disease in which sore throat is a symptom. Look into 
the sanitation and hygiene of each case. Accurately determine the 
date of the initial symptoms, so as to establish, if possible, the 



MEMBRANOUS PHARYNGITIS. 537 

period of incubation. Make a careful physical examination of the 
patient, taking the temperature in the axilla, or in the rectum if a 
child, not forgetting to examine the glands — cervical, submaxillary, 
and parotid. Then examine the throat b}^ the following method : 
Stand on the left side, facing in the same direction as the patient, 
who, if a child, is held on the nurse's lap ; or if an adult, he may 
be seated in a chair, sitting up in bed, or recumbent. Place 
the right hand firmly on the crown, so as to control by wrist- 
motion both the lateral and vertical movement of the head. Insert 
the tongue-depressor with the left hand, and bend your body 
forward, turning the face at the same time toward the patient's, 
and somewhat above the plane of his mouth. On the slightest 
tendency to cough, either rotate the patient's head by twisting the 
hand on the crown of his head, or remove your own face upward 
from the line of projection, at the same time depressing his face. 
Before using the tongue-depressor, have the patient open his 
mouth, and note the presence or absence of pain at the angle of the 
jaw. Pain and dysphagia point early in the disease toward ton- 
sillitis rather than diphtheria. While the patient is holding the 
mouth open, look carefully as to the condition of the gums, teeth, 
and entire buccal mucous membrane, not forgetting the roof of 
the mouth. Examine the half-arches, the uvula, and as much 
of the tonsils and pharyngeal wall as can be seen. Now intro- 
duce the tongue-depressor, and look carefully over the entire 
extent of the tonsils by forcing them out into view, if they 
are not enlarged already, by external manipulation or pressure 
on the root of the tongue with the tongue-depressor. Be spe- 
cially careful to examine the nasopharynx in all cases, for the 
membrane may be detected in this locality before it is observed 
elsewhere. Look, too, at the collection of glands at the base 
of the tongue, known as the Ungual tonsil. If a membrane be 
seen on the tonsil or elsewhere, try to dislodge it gently with 
a probe. If it tears away with difficulty, leaving a bleeding 
surface, the supposition is that it is bacterial in origin. Use 
the laryngoscope and the rhinoscope wherever practicable or pos- 
sible in laryngeal or nasal cases. Before making any medicinal 
application to the affected area, take a culture for bacteriological 
examination. If, when the examination is complete, the diagnosis 
is still in doubt, and there is the slightest leaning in your mind 
toward infection by the diphtheritic agent, treat the case exactly as 
if it icere diphtheria by giving a guardedly grave diagnosis pro- 
visional on the bacteriological finding. Isolate the patient, and, if 
the diagnosis of diphtheria be substantiated clinically or bacterio- 
logically, use prophylactic measures in all of the exposed cases. 

Prognosis. — From the initial symptoms to the height of the 
disease usually three or four days elapse. By this time in a mod- 
erate faucial case the membrane has ceased to extend : the tern- 



538 DISEASES OF THE PHARYNX. 

perature ranges from 100°-103° F., and the patient is not greatly 
distressed, either by the throat-involvement or the systemic infec- 
tion. The membrane now ceases to re-form and separates, leav- 
ing a surface tending to heal, and by the eighth to the twelfth 
day the throat has cleared up and convalescence is established. 
Deviation from this course means extension of the membrane or 
complications. 

The membrane in the above typical case has begun on the ton- 
sils, gradually covered them, and by the third or fourth day has 
climbed up the half-arches, invested the uvula and, perhaps, the 
posterior pharyngeal wall. Growth beyond this arbitrary limit 
means extension and further systemic intoxication. Prognosis in 
cases even of this character should be guarded, for there is no 
foretelling to what extent the membrane may grow, or what com- 
plication may at any moment render an otherwise favorable out- 
look exceedingly grave. It is to be borne in mind also that the 
systemic poisoning and symptoms may be disproportionate to the 
visible membrane ; that the slightly affected fauces, with severe, 
perhaps rapidly augmenting, prostration or unaccountable compli- 
cation, may be but part of the diphtheritic membranous infection, 
the rest of which is situated-out of sight farther down the aliment- 
ary or respiratory tract. Extension to the nose should be regarded 
as adding materially to the gravity of the prognosis because of 
the obstruction to breathing as well as the greater absorption of 
toxins through the rich supply of lymphatics in that structure. 
Should the membrane involve the larynx, the outlook is also ren- 
dered less favorable because of the obstruction to respiration. 
Rarely the membrane extends into the stomach by way of the 
esophagus and may even reach the intestines, when the lesion will 
be found in Peyer's patches — the intestinal tonsils. Such involve- 
ment, with its train of digestive and toxemic disturbances, is natur- 
ally of the gravest import. 

Temperature. — The temperature of diphtheria is prognostic 
to the extent that any sudden decided change beyond the usual 
limits means, if it suddenly falls, collapse ; while a corresponding 
rise indicates pus-formation or increase of septic absorption. 

Pulse. — A rapid pulse, not varying much in rate or rhythm 
for days, is not of unfavorable significance. Progressive accel- 
eration, however, with irregularity and loss of force, renders the 
outlook proportionately grave. 

Heart. — Cardiac involvement in diphtheria occurs in a number 
of cases, and should be regarded as of particularly grave portent. 
Death due to implication of the heart may be brought about, 
according to Lennox Browne, by (1) direct effect of the toxic poi- 
son on the heart ; (2) clots in the ventricles or great vessels of the 
heart ; (3) cardiopulmonary paralysis ; (4) vomiting and other 
causes acting through the vagus; (5) ulcerative endocarditis, myo- 



MEMBBASOUS PHABYNGITIS. 539 

carditis, and fatty degeneration of the cardiac muscle, which may 
cause death months after cessation of active symptoms. 

Lungs. — Extension of the membrane to the lungs, the entrance 
of particles of food, shreds of sloughing membrane, or of pus 
into the esophagus, and obstruction of the nares may cause, during 
the course of diphtheria, symptoms in the lungs which are at once 
alarming and extremely dangerous to life. Bronchopneumonia, 
septic pneumonia, pulmonary congestion, lobar pneumonia, and 
collapse of the lungs may be caused in this way, and their occur- 
rence renders the case so much the more to be despaired of. 

Kidney. — Albuminuria, as before stated, occurs in about one- 
third of the cases, and of itself is not of great prognostic impor- 
tance unless persistent. Reduction in the amount or suppression 
of urine, casts, epithelial cells, or hematuria are of far more grave 
import. Uremia may arise in the severer cases of kidney-involve- 
ment. It has been noted that in the uremic poisoning of diph- 
theria the intelligence has remained clear, up to the very end of 
life. 

Neuroses. — The neuroses arising in diphtheria are due to 
"acute segmentary neuritis," causing fatty degeneration of the 
muscles supplied by the diseased nerve, to toxic poisoning of the 
nerve-centers, or to the local ulceration which consumes the periph- 
eral nerve-filaments in its invasion of the tissue. The gravity 
of the neuroses from a prognostic standpoint depends on the stage 
of the disease when they occur and upon the role played by the 
affected muscle. 

The neuroses may occur (1) in the acute stage ; (2) during con- 
valescence ; (3) later than four weeks from the commencement of 
the disease. 

During the acute stage the cardiac or respiratory nerves may 
be involved in the toxic process, which may cause cardiac or pul- 
monary collapse or paralysis of the diaphragm. 

During convalescence the first muscles to be involved are the 
palatal, causing a nasal tone in the voice. Anesthesia of the pal- 
ate is associated at times. Morell Mackenzie has pointed out that 
infants may die in advanced palatal paralysis, due to their inabil- 
ity to suckle. 

Passage of fluids into the glottis and nasal regurgitation may 
follow paralysis of the muscles surrounding the laryngeal vesti- 
bule. The constrictors of the pharynx and the involuntary mus- 
cular fibers of the esophagus are rarely affected. 

Ocular paralysis affecting accommodation, and more rarely 
through the sixth nerve causing strabismus, has been observed. 
Ptosis also has been noted. 

Slight facial paralysis has been noted, and the trunk and limbs 
may be involved by both motor- and sensory-nerve manifestations, 
the sensory symptoms, such as hyperesthesia, formication, and 



540 DISEASES OF THE PHARYNX. 

neuralgia, occurring rather later in the disease than the motor. 
The bladder may be paralyzed, as may be the lower bowel and the 
rectum. 

Hughling Jackson calls attention to the fact that loss of reflex 
is an early prognostic symptom of nerve-impairment in diphtheria, 
and strict watch should be kept on the reflexes by way of antici- 
pating, if possible, the consequent nerve- involvement. 

Bacteriological. — Should the bacteriological examination show 
the presence of the Klebs-Loffler bacillus alone, the prognosis is 
more favorable than if it were associated with other organisms. 
The formation of membrane and the paralyzing effect on nerves 
and nerve-centers are to be considered as being especially due to 
the toxic action of the specific bacilli. The presence of streptococci 
in addition to the Bacillus diphtheria? augurs ill for the patient, 
because to their efforts are due the complications of the more 
malignant character, and rapid and phlegmonous glandular in- 
volvement, bronchopneumonia, nephritis, and other septic phe- 
nomena are to be expected. Staphylococci are found associated 
with the specific cause of diphtheria, and, while not especially 
vindicative of themselves, from association with more virulent 
organisms they complicate and render the prognosis more grave. 

Date and Mode of Death. — Sudden death in diphtheria 
may be due to suffocation from the membrane, spasm of the glot- 
tis, or toxemia during the first week. Paralysis of the respiratory 
or cardiac functions may cause death early or late. Formation of 
a clot in the heart or great vessels may cause death suddenly and 
unexpectedly. Death from kidney-complications may not occur 
for weeks. 

Treatment. — The treatment of diphtheria should be along 
the following lines, modified to suit the needs of the individual 
case : 

General Directions. — Isolate the patient in a well-lighted, 
well- ventilated, upper room, allowing 2000 cubic feet of air for 
an individual. Maintain the temperature of the room at as near 
65° F. as possible. Have all furniture, curtains, etc. removed 
before the case is admitted, except a plain cot-bed, rug on the 
floor, table, plain chairs, and receptacle for clothes. Impregnate 
the room, especially if the case be one of laryngeal involvement, 
with steam containing eucalyptol, carbolic acid, or lime water. 
Keep the patient quiet in bed. Do not let him rise to eat. Feed 
with feeding-cups or spoon, in this way avoiding the danger of 
sudden cardiac or respiratory failure due to exertion. Use the 
bed-pan for evacuations. 

Diet. — For the first few days give small quantities of concen- 
trated liquid food at frequent intervals, day and night. Beef-tea, 
milk, the yolk of raw eggs, broths given every two or three hours 
in amounts suited to the age and size, are satisfactory. Oranges and 



MEMBRANOUS PHARYNGITIS. 541 

lemon drinks are grateful and not injurious. Ice may be given as 
frozen milk or frozen beef-tea. Give no sweets or articles contain- 
ing sugar. As soon as the membrane has cleared, fish, fresh vege- 
tables, and rice pudding may be added, and a full, nourishing diet 
should be resumed as soon as possible. 

Local Remedies. — As soon as the case is seen, apply Loffler's 
solution with a cotton swab. Repeat every two hours, carefully 
covering the membrane and surrounding tissue with the solution. 
The throat should be sprayed every hour with equal parts of 
hydrogen peroxid, aqueous extract of hamamelis, and cinnamon 
water. In nasal diphtheria the nose should be kept clear by 
removing the occluding membrane and applying Loffler's solution, 
and by the use of the cinnamon- water and hydrogen-peroxid spray, 
Care should be taken to apply the agents to the postnasal area and 
the pharyngeal vault before the membrane has extended so far. 
Loffler's solution is highly germicidal ; it will destroy pure cul- 
tures of the Klebs-Loffler bacilli, as well as those of the organ- 
isms usually found associated with that germ, especially the strep- 
tococcus, when exposed to the solution for only a few seconds. 
The solution consists of: 

1^. Alcoholis absoluti, 60 parts. 

Toluol, 36 " 

Liquoris ferri sesquichloridi, 4 " 

The membrane is readily dissolved by it. Loffler himself 
obtained equally good results by substituting creolin for the iron 
in the above solution. Menthol can be added, 20 grains to the 
ounce, to relieve pain. Chloral 20 grains, and glycerin 2 drams 
to the ounce of water may be used in the same way for the same 
purpose. The use of ice-bags, or, preferably, Leiter's coil, applied 
externally to the neck, is grateful to the patient and will tend 
toward reduction of inflammation. 

Constitutional. — Begin the treatment of diphtheria by pre- 
scribing calomel in divided doses, T a T to \ of a grain with 1 to 2 
grains of bicarbonate of soda every hour until the bowels are 
freely moved. Often the milder cases require little else. Tinct- 
ure of chlorid of iron may be given in 4- or 5-drop doses hourly 
to a child of three years of age, and is an old and reliable mode 
of aiding the organism to combat the disease. 

Antitoxic Serum. — The use of the antitoxin as a curative and 
immunizing agent in the treatment of diphtheria has passed beyond 
the period of experimentation, and the success obtained by this 
mode of treatment in intelligent hands is remarkable. 

Immunity. — It is a well-known fact that age, condition, and 
previous attacks render individuals immune to certain diseases, 
and that measles, scarlet fever, and diphtheria are diseases of 



542 



DISEASES OF THE PHARYNX. 



childhood, rarely of adult and middle age, and in old age the indi- 
vidual is, with the rarest exception, immune. Again, it is a fact 
that of several children exposed alike to infectious diseases all 
may take the disease save one, who will resist the attack. This can 
be extended beyond individuals to exclude the fact that certain 
tissues of high grade resist infection and are practically immune ; 
for example, muscular tissue is rarely infected by tuberculosis. 
There must, then, be something within the cellular elements, either 
of the tissue or fluids, which enables the individual to resist infec- 
tion. The resistance secured by previous attack indicates that 
immunity can be acquired, and resistance to the disease without 
previous attack means that the individual is capable of manufac- 
turing a certain amount of immunizing material which increases 
his physiological resistance to disease. I believe this power lies 
largely in the leukocyte or the nuclein product. This degree of 
immunity varies in different individuals. 

If this assumption as to immunity be true, the individual does 
not nianufacture an antitoxin, but he does increase the capability 
of cellular elements to throw off or resist the invasion of the 
poison. On this theory is serum-therapy based, and upon its 
efficient aid to the defensive leukocyte does its success depend. 

Serum. — The serum I have most frequently employed is 
Behring's, although Mulford's, Parke Davis's, and Aronson's are 
probably just as good. Preference should be given to the prep- 
arations of high antitoxic unit- strength per cubic centimeter, and 
only standardized articles employed. 

Syringe. — A variety of syringes are manufactured especially 
for the injection of the serum, which are readily manipulated and 
sterilized. It is not at all necessary to have one of the special 
syringes ; any ordinary hypodermic syringe with a large needle 




Roux's antitoxin syringe. 



can be used, or even a new aspirating needle may be substituted, 
with precautions as to sterilization, which can be effected by boiling 
water and 5 per cent, tricresol. 

Injection. — The injections are made by pinching a fold of the 



MEMBRANOUS PHARYNGITIS. 543 

skin in the interscapular region or lateral abdominal wall and 
allowing the serum to enter slowly. After the desired amount 
has been introduced, the spot is covered with absorbent cotton, 
which forms a sort of collodion with the serum that flows back 
through the orifice, and thus completely closes it. 

A slight edema occurs during the injection, but disappears 
within fifteen minutes or half an hour. Xo serious objection can 
be raised against the injections, the only untoward circumstance 
being an occasional slight urticaria of no moment. Complications 
I believe to be due to faulty technic, imperfect sterilization, or a 
poor serum. Should the point of injection become sore, apply 
heat, either as hot-water bag or moist, warmed antiseptic dressing. 

Dose of Serum.. — In the serum we have a remedial agent that 
may be used preventively or therapeutically. The dose is given 
throughout in antitoxic units. 

When a case of diphtheria occurs, all who have been exposed 
should be protected by the injection of 500 units ; or if infection 
and incubation be suspected, the curative dose of 1000 units 
should be employed at once. These instructions may seem radi- 
cal ; but experience has proved their value, and their neglect may 
sooner or later cause regret. There is no danger of these doses, 
as clinical experience in skilful hands has proved that a person 
cannot be too immune. 

For a child of two to five years with suspicious throat-symp- 
toms or a moderately severe tonsillar involvement supposedly 
diphtheria, the dose should be 1000 to 1500 units. 

In well-marked faucial, nasal, or laryngeal cases the initial 
dose, in my opinion, should be a decided one, depending some- 
what, of course, on the age of the patient. But from 2,000 to 
10,000 units should be administered. The later the case is seen, 
the larger should be the dose. 

The physician should administer this remedy with prompt- 
ness and courage for effect, irrespective of dosage ; the following 
directions from J. Madison Taylor are so complete that they may 
serve as a guide in the general management of the quantity to be 
used : " If at the end of six hours the case is in the same condi- 
tion, repeat the dose of 2000 ; if it is worse, use a dose of 3000 ; 
if much better, wait until twelve hours have passed, then if the 
same condition, repeat 2000, or if ever so little worse, 3000 or 
4000 units at a dose. Then wait six or twelve hours, and repeat 
again if the same condition maintain — at six hours, 3000, if worse, 
4000 ; if better, wait until twelve hours elapse, and give 3000 
or 4000 units, making the third dose in a favorable case, or the 
fifth dose in an increasingly ill case. These three doses, or at 
most five, will usually be sufficient. 

" When the symptoms grow steadily worse, the dose may be 
repeated every six hours, increasing by 1000 at each injection, 



544 DISEASES OF THE PHARYNX. 

thus — 2000 units in six hours ; 3000 in six hours more (total, 
twelve hours) ; 4000 in six hours more (total, eighteen hours) ; 
5000 in six hours more (total, twenty-four hours) ; 6000 units at 
this last dose— continuing thus to increase if necessary. 

" There is a sign which is regarded as pathognomonic of improve- 
ment, which is described as a blood-red line surrounding the diph- 
theritic patch in the throat, noticed also in all healing infected 
inflammations, showing a demarcation between the diseased and 
healthy areas. The effect of the serum is to lower the tempera- 
ture ; hence, if after the first dose this still keeps high, the dose 
may be repeated in six hours, or all the more promptly and 
increasingly." 

Too much attention cannot be given to the early treatment 
of the disease. After the absorption of the alkaloidal products 
(toxins) which are generated at the point of infection, the func- 
tional activity of the cells is impaired ; the degree of impairment 
depends upon the resistance manifested by the patient and on the 
amount of toxin generated, as well as the length of time the 
cellular elements are subjected to the destructive influence of the 
toxins. If this has reached a stage of pathological alteration of 
tissue, we cannot hope to have in antitoxic serum a remedial 
agent ; it, no doubt, would arrest the progress of the disease and 
possibly enable the tissue to resist further infection. As to its 
effect on the germ, "It is a well-known fact that environment 
alters the characteristic feature of all germs. That in the descrip- 
tion of the germ, temperature, light, culture-medium, and absence or 
presence of other bacteria must be taken into consideration ; also the 
laboratory germs, which depend on artificial nutrition, differ some- 
what from those found in the body (see Fig. 212). This is especially 
true of the bacillus of diphtheria, which is demonstrated by the 
difference in the descriptions given by various authors. The 
alteration of the Klebs-Loffler bacillus, as due to the age and con- 
dition under which the germ was found and grown, has been the 
subject of careful study. Now, as to the effect of the blood- 
serum on the germ, it is not claimed that the antitoxin has any 
direct action ; but by counteracting the poison in the system pro- 
duced by the product of the germ, the resistance on the part of 
the patient manifested at the nidus of infection indirectly affects 
the germ's nutrition, thereby altering its character." 

Statistics show that when the treatment is begun on the first 
or second day of the disease, the mortality is reduced to almost 1 
per cent., but that it gradually increases when treatment is delayed, 
and by the fifth or sixth day the mortality is almost as high as 
when no serum is used. This points, then, to the immediate in- 
jection of the serum before serious tissue-alteration and profound 
toxemia have occurred. 

Even if this is an antitoxic agent, it must be remembered 



MEMBRANOUS PHARYNGITIS. 545 

that its action is largely constitutional, and that local treatment and 
even stimulating constitutional treatment should also be employed, 
employed. 

The infected mucous-membrane surfaces should be frequently 
and thoroughly cleansed and the patient stimulated. 

Stimulants should be given, in the form of brandy or whiskey, 
when the strength begins to fail. Nitrate of strychnin, aromatic 
spirits of ammonia, or digitalis is to be used if cardiac or respira- 
tory failure threatens, the dose to be sufficient to meet the require- 
ments of the case. 

Complications and Sequels. — Aural Diphtheria. — The 
involvement of the middle ear is not usually heralded by pain, 
and the first symptom may be the suppurative discharge from the 
meatus. Should this complication arise, syringe the ear with 1 
part boric acid and 25 parts water at 100° F., three or four times 
a day. 

Ocular Diphtheria. — Should the diphtheritic process involve 
the conjunctivae, which, however, rarely happens, Hermann Cohn 
of Breslau highly recommends hourly pencilling with 5 per cent, 
solution of benzoate of sodium. The use of bichlorid of mercury, 
1 : 5000, as an irrigation will effect a similar result. 

Laryngotracheal Diphtheria. — The use of steam surcharged 
with eucalyptol carbolic acid has been spoken of, and may be used 
under the so-called " bronchitis tent " — e. g., a sheet thrown over 
four broomsticks, one at each corner of the bed. A kettle contain- 
ing boiling water is arranged so that the impregnated steam shall 
pass under the sheet and keep the atmosphere moist and bland. 

An emetic given early may aid in the expulsion of loose pieces 
of membrane. The best emetic for a small child (one to five 
years) is wine of ipecac in teaspoonful doses every fifteen minutes 
until vomiting is produced. Leiter's coils, with cold water passing 
through them, applied externally to the neck are useful in affording 
some comfort to the distressed child. 

The throat should be frequently examined with the laryngeal 
mirror whenever possible, and the extent of the membrane 
observed and watched. In this way a small patch of membrane 
which might be the whole cause of trouble can be removed with 
forceps, avoiding the necessity of intubation or tracheotomy. 

Should progressive asphyxia threaten, as shown by suppression 
of voice, increasing dyspnea, stridor, cyanosis, and especially 
retrocession of the chest-walls, perform tracheotomy or do an 
intubation. 

The various factors compelling or indicating a choice between 
these two operations, as well as their description, will be found 
described on pages 777-793. 

Paralysis. — Strychnin should be pushed. Electricity may be 
used as soon as the acute stages have passed, either as the galvanic 
or faradic current. 

35 



546 DISEASES OF THE PHARYNX. 

Prophylaxis, Hygiene, and Disinfection. — As soon as 
suspicion points strongly to a case being one of diphtheria, it should 
be isolated. A room in the upper story of the house should be 
selected, from which all that is not absolutely necessary to the com- 
fort of the patient has been removed. Communication with the 
rest of the members of the household should be absolutely cut off. 
As soon as an absolute diagnosis is made, it should be reported as 
such to the relatives and to the authorities of the city or town. 
The practice in some localities of placarding the house as soon as 
diphtheria bacilli are found by the Board of Health bacteriologists, 
without consultation with the attendant physician or investigation 
into the clinical symptomatology of the case, seems a little too rigid 
enforcement of red-tape ; yet it is probably considered as the safest 
procedure to err on the safe side by protecting the community's 
welfare without thought of the individual. 

The room should be kept as well supplied with fresh air as pos- 
sible. A sheet moistened with a solution of bichlorid of mercury, 
1 : 5000, should be hung outside of the door, and the air in the 
room kept moist with steam. In cases of laryngeal or tracheal 
involvement eucalyptol may be added, in the proportion of \ 
ounce to a pint of water, and kept simmering over the flame. 

All excretion should be'carefully disinfected by the addition of 
bichlorid-of-mercury solution, 1 : 500. Every article employed in 
the sick-room should be carefully disinfected with a similar solu- 
tion, 1 : 2000, before it can be taken out for purpose of cleansing 
or for any other reason. This applies to the plates, cups, spoons, 
and all eating utensils, bed-linen, articles of clothing — in fact, any- 
thing removed from the room after the entrance of the affected 
patient. Old linen rags should be used instead of pocket-hand- 
kerchiefs, and should be burned as soon as no longer of use, as 
should all dressings, etc., employed in the treatment of the case. 
An old night-shirt might be kept in the sick chamber for the use of 
the attendant physician, which could be slipped over his ordinary 
clothes before examination of the patient and discarded as soon as 
the treatment has been finished, lessening in this way the only 
means of carrying the infection, if isolation has otherwise been 
carefully carried out. 

Lennox Browne speaks in this connection of the personal hy- 
giene of a sanitary engineer who always "blew his nose, gathered 
his saliva, and expectorated after he had inhaled any unpleasant 
effluvium ;" and the procedure might be carried out to advantage 
by the attendant or physician. 

All instruments employed in examination or treatment should 
be boiled for ten or twenty minutes or disinfected by the use of 
carbolic acid, 1 : 20. 

Care should be taken, while examining or treating the patient, 
that none of the membrane or oral contents is expectorated or 



MEMBRANOUS PHARYNGITIS. 547 

coughed up on the physician's clothing or face. If this should 
occur, promptly remove the expectorated matter with a cloth 
dipped in an antiseptic solution and thoroughly wash the affected 
parts. 

Should the case terminate fatally, all who have not previously 
been in the sick-room should be forbidden entrance, especially 
children. 

The patient's throat, if recovery takes place, should be treated 
with antiseptic gargles or sprays, such as — 

15*. Extracti hamamelidis, 
Aquae cinnamomi, 
Hydrogeni peroxidi, da equal parts. 

every four to six hours, and a bacteriological examination should 
be made each week until no bacilli are found. If the findings are 
negative three weeks after convalescence, it may be considered 
reasonably safe to permit the quarantine to be raised. 

Disinfection of Sick-room. — If the rules laid down before as 
to the removal of all unnecessary furnishings, bric-a-brac, carpets, 
curtains, and hangings have been carried out, the disinfection of a 
sick-chamber will not be especially difficult or expensive. Of the 
various methods of disinfection, that of the burning of sulphur has 
been the most generally used. One pound of sulphur should be em- 
ployed for every 1000 cubic feet of air-space to be disinfected. The 
room should be hermetically closed by pasting strips of paper about 
the windows and doors, the sulphur should be placed in a receptacle 
which should rest in a pan of steaming water ; other pans contain- 
ing water placed about the room will render this procedure more 
effective. After the room has been closed eight to twelve hours, it 
should be freely opened and allowed to air for twenty-four hours 
more. After this the wall-paper should be removed, the floors 
and woodwork scrubbed with soap and water and further cleansed 
with corrosive-sublimate solution, 1 : 1000, before it can reasonably 
be said to be safe for future occupation. Better than the employ- 
ment of sulphur for disinfection, because it is more efficient and is 
less injurious to goods disinfected, is the use of formaldehyd or for- 
malin. 

STREPTOCOCCIC INFECTION OF THE PHARYNX. 

In this form of infection, which involves the tonsils, palatine 
arches, and pharyngeal fauces, there is formed a distinct membrane 
over the areas involved. The bacteriological examination will es- 
tablish the diagnosis. The inflammatory process is not destructive 
and there is no ulceration. 

The symptoms are the same as any infectious process involv- 
ing these structures, although the systemic phenomena are not 



548 DISEASES OF THE PHARYNX. 

quite so marked as in diphtheria or scarlet fever. The course of 
duration is varied, depending largely on the degree of infection as 
well as the general condition of the patient. 

The treatment should be both local and constitutional. 



PNEUMOCOCCIC INFECTION OF THE PHARYNX. 

This form of infection of the pharyngeal mucous membrane, 
while infrequent, has been observed by some writers. The con- 
dition is characterized by sudden onset, intense congestion, and 
edema, with sudden and acute involvement of the anterior chain 
of cervical glands. The patient is rapidly prostrated. Occasional 
ulceration occurs. By extension of the disease through the Eus- 
tachian tube the middle ear and, in a few cases, the mastoid have 
been involved. 

The diagnosis is easily made by bacteriological examination. 

Symptoms. — In the aggravated cases the appearance of the 
membrane after ten days or two weeks resembles very much that 
of a tubercular condition. In a few cases reported tuberculosis 
followed this condition. The process sometimes extends into the 
larynx. A case is reported in which tuberculosis followed the 
pneumoeoccic infection, the tubercular condition ran a very rapid 
course, and the pulmonary involvement was extensive. 

GANGRENOUS PHARYNGITIS. 

Synonym. — Putrid sore throat. 

Gangrenous pharyngitis is purely a secondary condition, and is 
fortunately very rare. The process is always preceded by catarrhal 
inflammation of the mucous membrane, which, however, is depend- 
ent upon some infection, as the condition when it does occur is 
usually associated with the infectious fevers, such as scarlet fever, 
diphtheria, and typhoid fever, or it may follow trauma or opera- 
tive procedures. It is due to a local infection, or rather a localiza- 
tion of an infections process within the submucosa, which may be 
the result of infectious bacteria of the pathogenic variety floating 
in the circulation. There may lodge in the submucosa an infected 
embolus, which in turn gives rise to abscess-formation. The base- 
ment membrane is dependent upon the submucosa for its nutrition, 
and the latter being cut off by the infectious process, rapid necrosis 
takes place. The inflammatory products accumulate on the surface, 
and form over the area where necrosis is taking place a fibrinous 
material, which, when removed, carries with it a slough. It is really 
a localized superficial necrosis, and, as it involves the basement- 
membrane, gives rise to a true ulcer of the pharynx. This gan- 
grenous variety may also occur, due to local infection of bacteria, 
causing liquefaction-necrosis of the epithelial surface, and through 



OCCUPA TION-PHA R YNGITIS. 549 

the lymph-channels involving the deeper structures ; it really 
produces phlegmonous inflammation of such severity as to cause 
local death from bacterial processes, with resulting slough. The 
throat-manifestations come on suddenly and pursue a rapid course 
on account of the infectious nature of the process. There is usu- 
ally a rapid rise of temperature, owing to the absorption or presence 
within the system of toxins. When the condition goes on to actual 
necrosis, the temperature may suddenly drop to subnormal. The 
pain is usually severe and of a lancinating character. The cer- 
vical and submaxillary glands are nearly always involved. As 
the necrotic process advances, the breath is frightfully fetid — 
that characteristic odor from gangrenous tissue which cannot be 
described, but once detected will always afterward be recognized. 
Present always is marked prostration with mental depression, 
similar to that occurring in any septicemic process. The absorp- 
tion takes place not only from the local point of inflammation, but 
also from the gastric and intestinal tract, owing to the swallowing 
of the putrid masses. 

Prognosis. — The prognosis is bad, the patient usually dying 
from syncope. 

Treatment. — The treatment should be directed toward the 
underlying systemic infection. The secretory function should be 
stimulated, and remedial agents which aid in elimination should 
be administered. Stimulating medication should be instituted at 
the very onset. Locally, the surface should be repeatedly and 
thoroughly cleansed by disinfecting antiseptic solutions, such as 2 
to 5 drops of carbolic acid to the ounce. For relief from the dis- 
agreeable odor, a spray of permanganate of potash followed by 
hydrogen peroxid (15 volume) should be employed. 

OCCUPATION=PHARYNGITIS. 

Synonym. — Traumatic pharyngitis. 

Definition. — An acute inflammation of the pharynx, caused 
by wounds, foreign bodies, inhalation of various forms of dust, 
vapors, or caustic substances. 

Etiology. — This variety of pharyngitis is most commonly 
seen in children, since they are more liable than grown persons to 
accidentally drink corrosive liquids or boiling solutions. It may 
also be caused at any age by foreign bodies or the inhalation of hot 
air or steam. It may also occur in individuals who are constantly 
exposed to some variety of dust, as in sweepers, weavers, miners, 
etc. Chemists who are exposed to the fumes and vapors produced 
by chemical reactions during experimentation are also liable to 
the disease. The embedding of sharp foreign bodies, such as fish- 
bones, spicules of shell, splinters of bone or wood, pins, etc., in the 
tissue are also common causes. One case coming under my obser- 

32 



550 DISEASES OF THE PHARYNX. 

vation was caused by the inhalation of fine particles of glass from 
the brush used in burnishing the gold on hand-painted china. 
The minute particles of glass, being inhaled not only through the 
mouth but also through the nose, produced a marked irritation in 
all the upper respiratory tracts. When the inflammation is due 
to foreign bodies, it has its origin at the point of irritation and 
spreads to the surrounding tissues. If the wound caused by the 
foreign body involves the submucous connective tissue, it is quite 
likely to give rise to suppuration and abscess-formation. In the 
varieties of inflammation caused by vapors, fluids, or fine particles 
of dust, the whole pharyngeal structure is more regularly involved, 
there being no localized nidus of inflammation ; besides, the con- 
tiguous mncous-membrane structures are implicated. In the 
varieties brought about by escharotics, scalds, or burns, there is 
great danger of immediate edema of the glottis, as the irritation 
would not be limited to the pharyngeal structure alone, and even 
if it were, that tissue would rapidly become edematous. Regard- 
less of cause, this variety of pharyngitis runs a rapid course and is 
accompanied by exaggerated inflammatory phenomena. 

Treatment. — When a foreign body is the exciting cause, if it 
can possibly be located it should be promptly removed. Fre- 
quently, though, when a patient presents himself for treatment, the 
body has been discharged, and there is left the infected wound 
with the subsequent inflammatory area. Where there is threat- 
ened edema, frequent multiple punctures should be made under 
antiseptic precautions. Locally, to relieve the pain in scalds, burns, 
etc., there is nothing better than smearing the parts freely with 
carbolized vaselin to which has been added 4 grains of menthol to 
the ounce. Its protective qualities may be increased by rubbing 
into each ounce thoroughly an ounce of compound tincture of 
benzoin with equal parts of 50 per cent, boroglycerid. Cold ex- 
ternally may aid in combating the inflammatory process. The 
edema may be so rapid as to necessitate resort to intubation or 
tracheotomy. However, if the inspired irritant has caused involve- 
ment of the larynx and trachea, the edema may extend below a 
point which would be relieved by such procedure. The internal 
administration of opium or morphin is always beneficial ; and, as 
a local sedative, insufflation of morphin, i to \ grain in precipi- 
tated chalk or stearate of zinc two or three times daily, affords 
great relief. This should not be repeated oftener than every four 
hours. Of the numerous escharotics which might be the exciting 
cause of traumatic pharyngitis, it is impossible to give the various 
antidotes that would neutralize their caustic effects. At the same 
time the action of such irritants is so rapid that little benefit would be 
derived from the internal administration of antidotes. The treat- 
ment always indicated is to relieve the pain by anodynes and the 
local application of emollients. After the subsidence of the acute 



HEMORRHAGIC PHARYNGITIS. 551 

symptoms the main treatment is the thorough cleansing by bland 
alkaline antiseptic washes, such as boric acid 8 grains; carbolic 
acid 3 drops to the ounce of water. 

HEMORRHAGIC PHARYNGITIS. 

Definition. — By this variety of inflammatory process of the 
pharyngeal structure is meant inflammation that is brought about 
by minute areas of hemorrhagic infarction caused by rhexis. 
Although this condition may occur in association with an acute 
inflammatory process, in the true hemorrhagic variety this inflam- 
mation is always secondary to hemorrhage. It frequently occurs 
after an attack of illness, especially of the eruptive fevers, in which 
there is altered vascular tone with relaxed vessel-walls and lax 
perivascular tissue. The hemorrhagic areas are very small, and 
show as small, dull-red, slightly edematous spots. If seen early 
they will exhibit very little, if any, inflammatory reaction ; but 
after twenty-four to forty-eight hours they will show considerable 
evidences of inflammation. These areas may be located anywhere 
in the pharyngeal surface ; but they are usually on either side of 
the median line. They may be single, although generally multiple. 
Where the hemorrhage is very slight, it will resemble more the 
petechia? of eruptive fevers. Frequently in the specific inflamma- 
tory processes, especially syphilis and tuberculosis, where altera- 
tion in blood-vessel walls is a common event, these hemor- 
rhagic areas will be observed not only on the pharyngeal, 
but also on the mucous-membrane surface of the soft palate 
and uvula. The symptoms are similar to those of acute pharyn- 
gitis, but are likely to be of longer duration. Occasionally, 
there may be expectorated slightly blood-stained mucus. The 
pain is more localized than in ordinary acute pharyngitis, and 
usually not severe. Occasionally, necrotic changes may take place 
in the area of infarction, owing to the cutting off of the blood - 
supply ; and the minute portion sloughing off gives rise to ulcera- 
tion, which is described as hemorrhagic ulceration of the pharynx. 

Treatment. — The treatment should be directed toward the 
correction of any constitutional diathesis as well as the relief of 
any tendency to constipation. Locally, the throat should be 
repeatedly gargled with hot water, Avhich will materially aid in 
re-establishing circulation. Of the local applications, those afford- 
ing the most relief are the astringents, in the form of a 3 to 
6 per cent, alumnol solution or 5 to 10 grains of sulphocar- 
bolate of zinc to the ounce of water. However, the local appli- 
cations will only relieve the accompanying inflammation, and 
the treatment given under Acute Pharyngitis (page 524) is also 
applicable here. 



552 DISEASES OF THE PHARYNX. 



GLANDULAR PHARYNGITIS LATERALIS. 

This is frequently noticed on the lateral walls of the pharynx 
bordering on the anterior edge of the posterior pillar, inflamed 
areas varying from one to five or six and extending in the 
line of the pillar. This may be only on one side, or both sides 
may be involved. The central pharyngeal surface shows no evi- 
dence of inflammation ; in other words, the inflammatory change 
has taken place in the chain of lymphatics following down the 
lateral wall of the pharynx. 

Etiology. — There are a number of causal factors associated 
with this condition. It may follow a local infection of the naso- 
pharyngeal tonsil or buccal membranes, the infectious diseases, 
such as measles, scarlet fever, diphtheria, and typhoid fever. 

It is also frequently associated with faulty digestion, whether 
gastric or intestinal. 

It may also follow an ordinary cold, or be associated with or 
following an attack of influenza. 

The so-called lymphatic type of individual is more predis- 
posed to this form of pharyngitis than any other. 

Besides the constitutional conditions, such local irritants as 
excessive smoking or chewing and inhalation of irritants, infec- 
tious catarrhal conditions of the nasal cavities and also of the 
accessory cavities, especially the ethmoid and sphenoidal cells, may 
act as exciting factors. 

The condition is frequently observed in persons who are 
addicted to the use of liquor and tobacco. 

Symptoms. — The main symptom is the irritating, rasping, 
hacking cough. There is not much expectoration, but the patient 
has the sensation of some foreign body in the throat and a 
constant tickling and irritation keeps up the rasping, hacking 
cough. The cough varies only slightly during the day and night ; 
in some few cases it is more pronounced when the patient is in the 
recumbent position. 

There is very slight pain, except on swallowing, and this is 
increased during eating, the swallowing of liquids being less 
painful than swallowing solid food. 

Although the cough is persistent there is rarely ever any in- 
volvement of the bronchial tubes or air vesicles, unless there is 
associated or allied disease. 

Occasionally, where the glands are involved high up in the 
vault of the pharynx, there may be symptoms referring to the ear, 
slight deafness, ringing in the ears, and a sensation of fulness, with 
occasionally slight earache. 

Pathology. — The condition is an inflammatory one, involv- 
ing the lymphoid tissue of the lateral tracts of the pharynx. This 
lymphoid tissue resembles somewhat the adenoid tissue of the 



■-& 



PHARYNX IN EXANTHEMATA AND FEBRILE AFFECTIONS. 553 

nasopharynx, and extends from just below the Eustachian tube 
along the anterior border of the posterior pillar of the fauces 
down to a line corresponding to the rim of the glottis. The inflamed 
masses are oval in shape, smooth in appearance, and sometimes 
coated over with thick, tenacious mucus. It is usually seen 
in the acute form, although it may become chronic. The inflamed 
glands, owing to the involvement of the surrounding aud interven- 
ing tissue, may give the appearance of having run together and 
forming one continuous, elevated, inflamed area. 

Treatment. — Internal medication should be directed toward 
the relief of any underlying systemic condition. The intestinal 
tract should be stimulated. Any errors of diet should be cor- 
rected. The liver should be rendered active by thorough purga- 
tion. Following this, ten- to fifteen-drop doses of dilute hydro- 
chloric acid given in a half-glass of water after each meal gives 
excellent results. 

Tonic alteratives are also beneficial in cases which follow 
infection and where the individual's general condition is below 
par. 

Applied directly to the inflamed areas by means of the appli- 
cator and a pledget of cotton, equal parts of compound tincture 
of benzoin, 50 per cent., or a 15 per cent, solution of alumnol, 
will tend to reduce the swelling and relieve the irritating cough. 
Equally good results may be obtained by a 30 per cent, solu- 
tion of argyrol or a 2 per cent, solution of sulphate of zinc. 

The areas should not be cauterized. 



THE PHARYNX IN THE EXANTHEMATA AND OTHER FEBRILE 

AFFECTIONS. 

Scarlet Fever. — Although there seems to be some difference 
of opinion as to the occurrence of involvement of the pharynx in 
every case of scarlet fever, it would appear that the statement — 
the disease in the throat is the most regular in its appearance of 
all the symptoms of scarlatina — is a safe one. Commencing with 
a certain amount of redness as early as the occurrence of the fever, 
the throat-lesions may be of varying degrees of severity. 

According to Osier, they may be classified in three groups — 
first, slight redness, with swelling of the follicles of the tonsils ; 
second, a more intense grade of swelling and induration of the 
parts, with follicular tonsillitis ; third, membranous angina, with 
intense inflammation of all the pharyngeal structure and swelling 
of the glands below the jaw, and in very severe cases a thick, 
brawny induration of all the tissues of the neck. The condition 
of the pharyngeal mucosa is almost pathognomonic of scarlatina, 
and consists of a " deep bluish-red injection of the mucous mem- 
brane and tonsils in the neighborhood of the highly swollen 



1 



554 DISEASES OF THE PHARYNX. 

papillae of the posterior portion of the region of the cricoid carti- 
lage and that portion of the pharynx which includes these different 
parts." Even in comparatively mild cases the inflammatory proc- 
ess may extend over the pharynx and involve the Eustachian 
tube and the lining membrane of the ear, most likely complicated 
with pre-existing enlargement of the pharyngeal tonsil, which is a 
suitable nidus for infection. 

Ulceration of any other part of the throat than the tonsils 
usually does not occur before the fifth day, except in the severest 
cases, although the excess of the secretion of the parts spread over 
the surface is very liable to be mistaken for sloughing. 

Membranous inflammation of the pharynx, if occurring early in 
the disease, or even later than the fifth or sixth day, may be due 
to the action of the Klebs-Loffler bacillus, which would be purely 
diphtheritic in type, or to the influence of streptococci or various 
forms of micrococci. In streptococcic infection the invasion is 
more apt to involve deeper structures and to cause sloughing and 
even gangrene. Inflammation of the lymphatic glands is almost 
always induced in such conditions. With the discharge of the 
sloughs there is an offensive odor ; the sloughs may lay bare the 
cartilage and bone. 

In malignant scarlatina the throat-affections are proportionate 
to the systemic involvement. 

Treatment. — In all cases of scarlet fever in which the throat- 
lesions are severe, external applications to the neck are indicated, 
and in the early stages should consist either in the Leiter coil, the 
rubber bag filled with cracked ice, or the application of cloths 
wrung out in cold water. Later, the application of heat, either 
dry or moist, is equally efficacious. Detergent and antiseptic 
spray-applications are indicated locally. Hydrogen peroxid of 
full strength, or mixed with cinnamon-water, peppermint-water, 
and extract of hamamelis, in equal parts, may be used as a spray ; 
or the folloAving used in the same manner : 

ly. Sodii bicarbonatis, 

Sodii biboratis, da gr. x (.6) ; 

Acidi carbolici, Tftv (.3) ; 

Aquse cinnamomi, 
Aquae menthse piperi-tae, da fl^ss (15.). — M. 

Small-pox. — The throat-trouble in small-pox often com- 
mences during the stage of infection, or even during incubation, 
and in some cases consists of a dusky injection of the mucous 
membrane of the pharynx, and in others amounts to a catarrhal 
inflammation, with redness and swelling of the adjacent parts, which 
in rare instances extends to the lymphatics. In the hemorrhagic 
small-pox the throat may be involved in ecchymoses and mem- 



PHARYNX IN EXANTHEMATA AND FEBRILE AFFECTIONS. 555 

branous exudation before the eruption appears upon the body. As 
a rule, however, the eruption proper does not appear in the throat 
until after its development upon the skin, and is modified by the 
fact that the structures of the mucosa diifer from the ordinary 
epidermis. Pseudomembrane may develop in some cases, causing 
great pain, discomfort, and difficulty in deglutition. Among the 
complications and sequels of small-pox are infectious inflammation 
of the parotid and other glands, purulent otitis media, and abscess 
of the larynx. 

On account of the excessive soreness and pain in the pharynx, 
especially in the complicated variety of the disease, applications 
of cocain and menthol may be indicated. A gargle of chloral 
hydrate 5 to 10 grains, and glycerin J dram to the ounce of water, 
is equally soothing. External applications of cold or heat, which- 
ever is more gratefully borne, may be of service. Disinfectant 
gargles, sprays, or applications are to be used, however, as in any 
other acute inflammation of the pharynx. 

Measles. — Although there seems to be some discussion in 
regard to the importance of the prodromal rash occurring in 
measles, yet there is no doubt but that the involvement of the 
faucial and pharyngeal mucous membrane does occur in a manner 
thoroughly characteristic of the disease. There may be merely a 
diffused redness upon the mucous membrane extending over the 
palate and uvula, and sometimes on the pharynx a blotchy or 
punctate rash, which either occurs conjointly with or may ante- 
date by a few hours or days the appearance of the cutaneous erup- 
tion. The catarrhal inflammation which always involves the upper 
respiratory tract in measles spends most of its force on the larynx 
and bronchial mucosa. Extension of the inflammation over the 
pharynx and aural cavities is one of the complications which is to 
be mentioned only to be avoided, if possible, by proper prophylac- 
tic measures. 

Coating the membranes with carbolized vaselin to which has 
been added one dram of compound tincture of benzoin is highly 
efficacious. Apart from this treatment, the ordinary alkaline 
detergent and antiseptic sprays will answer for all the symp- 
toms arising from the involvement of the pharynx. 

Krysipelas. — Erysipelas of the pharynx occurs primarily or 
may be found as a secondary complication of the cutaneous mani- 
festation of the disease. The ordinary redness with diffuse inflam- 
mation, in which the tissues are swollen, livid, and shining, the 
formation of vesicles, varying from the size of a pin-head to J inch 
in diameter, which terminate in gangrene, embraces probably the 
full extent of the involvement of erysipelas. The constitutional 
manifestations are most marked. Epidemic erysipelatous fever, 
commonly known as " Black tongue,'' may involve the pharynx 
and even extend to the larynx. When the pharynx is involved 



556 DISEASES OF THE PHARYNX, 

by extension from without, the process may enter by the mouth, 
the nose, or the ear by continuity of tissue, or there may be a 
metastatic interchange between the cuticle and the internal position 
of the disease. Erysipelas of the pharynx begins with difficulty 
in swallowing, or with a sharp pain in the throat, ushered in by a 
high fever, which may last for a few days before the efflorescence 
makes its appearance. When this occurs, the fever may or may 
not decline, again to ascend on further development of the erup- 
tion. The membrane, swollen and glistening, appears as though 
varnished, and here and there may be found vesicles filled with 
serum, blood, or pus. Gangrenous areas may develop. Exten- 
sion to the accessory sinuses, the tonsils, and the middle ear may 
occur in almost all cases where there is glandular involvement. 
Abscess may result, and in severe cases meningitis may follow. 
Involvement of the pharynx alone, without extension, is com- 
paratively rare. Erysipelas may occur in this locality as a com- 
plication of small-pox, typhus or typhoid fever, and other febrile 
diseases. 

The prognosis should be guarded in all cases, because of the 
possibility of fatal termination by extension and involvement of 
the larynx or other contiguous or continuous structures. 

Treatment. — Tincture of chlorid of iron should be given in 
large doses, \ dram to a dram every two or three hours, well 
diluted in water. Alcohol in some of its forms, strychnin, or 
other supportants should be administered freely. Locally, there 
have been a number of remedies offered, and from their very 
great profusion there can be no other inference than that no 
one is especially efficacious. Ice, externally and internally, soothes 
the membranes and perhaps acts beneficially. Ichthyol, 40 per 
cent., painted over the affected area, is highly beneficial. Hydro- 
gen peroxid exerts some germicidal influence, and should be 
applied by means of a cotton swab. 

Intermittent Fever. — Intermittent fever, evidencing an 
irritation or alteration in the blood, due to the infection of the 
parasite of malaria, may be manifested in the upper respiratory 
tracts, and the inflammation may involve the mucous membrane 
from the nose to the smallest division of the lung. These evidences 
of involvement may appear as attacks of coryza, or in certain 
cases paralyses of the organs of deglutition have been observed. 
Burning pain in the pharynx has also been noted as a symptom. 
Pharyngitis or tonsillar enlargement may be observed as a local 
manifestation of the systemic involvement. 

Treatment consists in combating the malarial infection. 

Gout. — Inflammatory conditions of the pharynx or larynx, as 
local manifestations of the general systemic involvement, undoubt- 
edly do occur. As with the supervention of the acute podagral 
attack the throat-affections have disappeared, the irritant cause of 



PHARYNX IN EXANTHEMATA AND FEBRILE AFFECTIONS. 557 

the general affection probably evidences itself in this inflam- 
mation of the mucous-membrane structures in the pharynx and 
larynx. 

Typhus Fever. — In this disease the mucous membrane of the 
pharynx usually becomes involved, as does the mucosa of the 
mouth, and appears dusky red, injected, with enlargement of the 
mucous follicles, which contain puroid material, or collections 
of puriform matter may be found in the areolar tissue behind the 
pharynx. The membrane may be covered with a viscid mucus or 
with flakes of pseudomembranous exudation. Difficulty in swal- 
lowing may occur. Suppuration or ulceration is rarely seen, unless 
streptococcal infection occurs. 

The treatment should be that appropriate to the general dis- 
ease, with the addition of cleansing and antiseptic sprays and 
gargles. 

Typhoid Fever. — In a considerable number of cases both 
the pharynx and larynx are involved in typhoid fever, though 
affections of the latter are more serious than those of the former. 
Catarrhal, follicular, ulcerated, croupous, or diphtheritic and aph- 
thous inflammations of the pharynx are met with. Difficulty in 
swallowing, due to the dryness of the throat, is very often com- 
plained of at the beginning of the disease. Later on, it may be 
a purely nervous affection. Especially is this true in children. 
There is usually a certain amount of injection of the pharyngeal 
mucous membrane, but actual sore throat is comparatively rare. 
It has been stated that the follicles of the pharynx and tonsils, 
faucial or lingual, may be involved coincidently with the intes- 
tinal glandular implication. In fact, there may be rare cases in 
which the amount of infection is so great that the name tonsillo- 
typhoid or pharyngotyphoid has been applied. Since the involve- 
ment of the typhoid process is more to be feared in the direction 
of necrosis of some of the bones and cartilage, or abscess-forma- 
tion, the lesions of gravity are rather to be expected in the larynx 
than in the pharynx, and such is the actual state of affairs in the 
majority of cases. The frequency of such complications and sequels 
has been shown by Keen in his w r ork on " The Surgical Compli- 
cations and Sequels of Typhoid Fever." 

Influenza. — With the majority of cases of epidemic influenza 
(" la grippe "), particularly of the pneumonic variety, an inflam- 
mation of the pharynx will be associated. Though characterized 
by no especial peculiarity as to type, the affection is usually found 
as an acute catarrhal process, involving the pharyngeal mucosa 
only as part of the more general implication of the upper respira- 
tory tract, with decided tendency to become chronic. The char- 
acter of the inflammation is influenced to a great extent by the 
organisms associated with the bacillus of Pfeiffer in the produc- 
tion of the condition. Ulcerative termination of the process, 



558 DISEASES OF THE PHARYNX. 

while uncommon, has been observed, as has croupous deposit on 
the tonsils and posterior pharyngeal wall. 

Varioloid. — The pharyngeal involvement of varioloid is 
usually slight, the eruption being, as a rule, scantily developed, 
though occasionally it may give rise to considerable inflammation, 
with dysphagia and hoarseness. 

Chicken-pox. — If the cutaneous eruption of chicken-pox be 
at all abundant, involvement of the pharynx may be looked for ; 
though more numerous on the soft and hard palate. Usually 
appearing as flaccid vesicles surrounded by an area of hyperemia, 
the epithelial cells covering the vesicle soon desquamate and leave 
excoriations. The throat is usually sore and painful, and there 
may be some involvement of the glands of the neck. 

Treatment other than that addressed to the disease in general 
is not necessary, except the ordering of a gargle that will soothe 
the parts and promote healing. The following may be employed 
to advantage : 

ly. Tincturse cinchona? composite, fl^ss (15.) ; 
Menthol, gr. xv (.9) ; 

Glycerini, q. s. ad fl^j (30.).— M. 

Sig. — One teaspoonful every three hours in one ounce of milk as 
a gargle. 

LUDWIG'S ANGINA. 

Synonyms. — Angina Ludovici ; Cellulitis of the neck. (See 
p. 657.) 

This affection is in reality an acute cellulitis of the neck, and 
is usually secondary to the infectious fevers, especially diphtheria 
and scarlet fever. Though at times due to trauma, this affection 
is in all probability bacterial in origin. Symptoms of intense 
streptococcic infection in the throat, especially of the pharyngeal 
portion, are soon followed by glandular, parotid, or submaxil- 
lary infection, which rapidly goes on to suppuration. Unless met 
promptly by energetic surgical procedure, general systemic involve- 
ment is sure to follow. 



VINCENT'S ANGINA. 

An ulcerative disease of the mouth and throat, probably 
caused by the fusiform bacillus and spirillum of Vincent. 

The failure of many laryngologists and pediatrists to recognize 
Vincent's angina is due to their attention not being especially 
called to its clinical features. It begins as a grayish necrosis, 
resembling the diphtheritic membrane. When this sloughs it 
reveals an ulcer often half- to three-quarters of an inch in depth. 



ANGINA ULCEROSA BENIGNA. 559 

Sometimes the tonsil is leveled off as if by operation. Almost 
identical bacteria are seen in pyorrhea alveolaris. The majority 
of cases occur in children, although it may occur in adults. The 
symptoms are those of a sudden acute sore throat ; there is also a 
possibility of contagion. The ulcer heals in from one to three 
weeks. The patient should be put to bed and given a gargle of 
sodium bicarbonate and boric acid. Examinations should be made 
at once for bacteria, and both a fresh smear and a culture should 
be examined. The germs are two in number and the characteris- 
tic clinical picture appears only when both are present. There 
may be a symbiosis, or the two may be a morphological variance 
of a single germ. 

There are two varieties — a superficial type limited to the epi- 
thelium, and a deeper process associated with membrane forma- 
tion and ulceration. The membrane consists of necrotic tissue 
masses and numerous fusiform bacilli, and spirochete are present 
in pure culture. The relation between this angina and ulcer- 
ative stomatitis is noticed in the clinical, pathological, and bacteri- 
ological conditions. The pressure of the teeth against the gums 
and oral mucous membrane explains the deep necrosis occurring 
always in the stomatitis. The angina begins primarily as an 
atypically placed stomatitis, though it may be combined with a 
typical ulcerative stomatitis, and in some few cases the tonsillar 
process has even been traced to a typical occurrence in the 
mouth-cavity proper. No definite decisions can be made regard- 
ing the bacteria of the disease. The fusiform bacilli are the 
producers of the characteristic symptom complex, but their rela- 
tion to pyogenic organisms is not clear. The spirochete are prob- 
ably unimportant parasites. The remarkable similarity to noma, 
clinically, pathologically, and bacteriologically, leads to the sup- 
position of a close relation between it and necrotic ulcerative 
angina. Diphtheria must be differential from Plain? s or Yin- 
cent's angina ; the absence of diphtheria organisms is the deciding 
point ; yet the two may coexist. 

ANGINA ULCEROSA BENIGNA. 

This variety of ulceration was first described by Heryng, in 
1890. The disease usually appears on the anterior faucial pillars, 
and is usually a single superficial ulcer or excoriation. The 
edge of the ulcer is clear cut and well defined, although deep 
ulceration never occurs. The surface is usually grayish in color 
and the surrounding mucous membrane shows slight, if any, evi- 
dence of inflammation. The basement membrane is not involved 
in the excoriation, so that when the ulcer heals it leaves no 
cicatrix. Occasionally the ulceration is bilateral. The patient 
complains of considerable pain on swallowing ; in fact, pain out 
of all proportion to the area involved. At the onset of ulcer- 



560 DISEASES OF THE PHARYNX. 

ation the patient may show slight fever. No specific micro-organ- 
ism has been definitely isolated. A number have been found 
present in the dead epithelium coating the ulcer, but their etio- 
logical relation has not been established. The disease is indeed 
rare. 

SIMPLE CHRONIC PHARYNGITIS. 

Synonyms. — Clergyman's sore throat; Voice-users' sore throat; 
Exudative pharyngitis. 

Definition. — A chronic catarrhal inflammation involving the 
mucous membrane of the pharynx, in which there are permanent 
alterations either within the gland-structure or in the submucous 
connective tissue. 

Etiology. — This condition may be the result of a continued 
acute or subacute pharyngitis. It is a well-known fact that from 
the continued use of the voice, as in public speaking, there is a reac- 
tionary muscular contraction of the larynx and pharynx, with 
forced local anemia of the part, and that after the pressure from 
muscular contraction is taken off there is stasis and dilatation of 
the vessels. This often repeated will bring about changes in the 
perivascular tissue almost identical with those of chronic inflam- 
mation. The pathological condition produced is very much the 
same as that due to a cyanotic congestion. Although there is an 
excess of blood to the part, it is not nutritive, and the peri- 
vascular tissue is subjected to pressure, thereby lessening its nutri- 
tion as well as the blood-supply itself. While the causes of the 
pathological alteration in the structures and the symptoms pro- 
duced may differ, yet the actual change is the same. Simple 
chronic pharyngitis may be brought about by continuation of acute 
processes, or may be due to constitutional conditions in which 
there is alteration in the blood-supply, produced by venous stasis 
or cyanotic congestion, owing to interference in circulation in the 
various organs, as the liver, kidney, lungs, or to cardiac lesions. 
Peculiar nervous phenomena, peripheral in origin, also exercise 
considerable influence on the causation of the condition. This 
may either consist in a primary lesion or may be due to an involve- 
ment of the peripheral nerves in other pathological processes. 
Irregularities in the digestive tract also exert considerable influ- 
ence. The continued use of any stimulant, such as alcohol or 
tobacco, or the excessive use of narcotics, will eventually produce 
the same condition. Frequently the so-called u rum cough " is 
brought about by circulatory changes arising from the alcoholic 
stimulation. Sexual excesses also exert a marked influence. The 
chronic irritation produced by smoking is in reality not only a 
local one, but a local manifestation of a constitutional condition 
brought about by the absorption of the various alkaloids of tobacco 
— namely, nicotin and pyridin. The various forms of pneumono- 



SIMPLE CHRONIC PHARYNGITIS. 561 

koniosis are also exciting factors, although they properly belong 
under Traumatic Pharyngitis or Occupation Pharyngitis. At the 
same time the irritation is productive of a chronic inflammatory 
process. Certain constitutional diatheses, such as a gouty, or uric- 
acid, or blood dyscrasia due to the absorption of toxins from the 
intestinal tract, or any lesion that interferes with the excretory 
or secretory organs, are also important etiological factors, either 
primary or secondary. Constitutional conditions, such as tuber- 
culosis and syphilis, in which there is alteration in the blood- 
vessel wall, may also show manifestations in the lax mucous- 
membrane structures. Irregularities in the formation of the 
pharynx, especially the condition known as slanting pharynx, is an 
important causal factor. Another cause of chronic pharyngitis, 
as observed in singers and in speakers, is unquestionably the 
improper use of the muscles of phonation and articulation, owing 
to improper breathing, in which the faucial and laryngeal muscles 
are overtaxed, or increased work is thrown upon the structures 
by the increased vascular supply. There will be produced in 
this manner certain alterations in the connective-tissue elements, 
which will produce symptoms identical with chronic pharyngitis, 
although they cannot be properly classed as inflammatory changes. 
The various forms of rhinitis occurring in the mucous membrane 
of the anterior or posterior nares are also important factors. While 
the inflammatory process may not actually spread by contiguity of 
structure, yet by the discharge of the irritating material over the 
pharyngeal wall from the nasopharynx, the irritation will event- 
ually produce a chronic inflammatory change in the pharyngeal 
structure. This may be due not so much to the immediate action 
of the irritating material on the mucous membrane, as to the con- 
stant effort of the individual to clear the throat of irritating 
material. Together with the long-continued use of the voice and 
the muscles of phonation, there must also be considered the forced 
use, as is observed in outdoor speakers, where the individual, of 
necessity, in his efforts to be heard by his listeners, exerts tre- 
mendous effort in speaking. Combined with this effort is the 
atmospheric condition, which is an aid to the irritation that very 
rapidly produces marked inflammatory changes in the pharyngeal 
structures. This is a condition in which there may have been 
originally very little inflammatory process present, but by the re- 
peated engorgement of the vascular system there has been brought 
about an overnutrition, and in the relaxation that always follows 
the continued use of the voice there has taken place a leakage 
from the blood-vessels into the perivascular tissues, and the inflam- 
matory condition there produced is secondary to the congestion. 
Combined again with the excessive use of the voice, individuals 
speaking in public buildings where vast crowds are assembled have 
also to contend with the irritating effects of the dust. This alone 

36 



562 DISEASES OF THE PHARYNX. 

is sufficient to produce irritation and inflammatory changes in the 
upper respiratory tract. 

The condition is also found in persons in whom there is 
obstructed nasal respiration, either anterior or posterior, due to 
malformations, septal deflections, or neoplasms. This is due to the 
fact that on account of the interference with nasal respiration 
mouth-breathing becomes necessary, and the inhalation of air that 
has not been cleared of dust, or moistened, or reduced to the proper 
temperature acts as a direct irritant to the pharyngeal mucous- 
membrane surface. 

This will often explain cases of repeated attacks of acute 
pharyngitis where possibly the individual has been so placed in 
the sleeping apartments that he inhaled directly the warm, dry, 
and dusty air from the register. Also adding to the irritation are 
the coal-gases generated from the base-burner. 

Pathology. — The pathological alteration occurring in the 
pharyngeal membrane in chronic pharyngitis varies, and many of 
the chronic forms of pharyngeal lesion are entirely dependent upon 
the stage of progress of the inflammatory process. Take, for 
example, a simple chronic pharyngitis, in which there is a slow 
inflammatory change in the submucous connective tissue. Grant 
that the irritating cause is sufficient only to bring about a low 
grade of inflammation, in which there is a slight exudate from the 
blood-vessels, with few migratory leukocytes, with their gradual 
proliferation in the connective-tissue spaces. This, together with 
slow proliferation of the fixed connective-tissue cells, will bring 
about a permanent thickening of the pharyngeal mucosa. At this 
stage, by the increase in the connective-tissue element, there will 
also be produced a certain amount of irritation within the gland- 
ular elements, with hypersecretion, by the irritating material that 
brought about this increase. As this inflammatory material organ- 
izes, by its actual bulky presence it will press upon the glandular 
elements in the submucosa. Now, as inflammatory organized con- 
nective-tissue elements are sure to undergo contraction, it brings 
about an entirely different condition, as at this time the inflammatory 
stage is past and the condition is not now one of inflammation • but 
as the tissue is suffering rather from the effects of an inflammatory 
organized tissue and from the contraction of the submucosa and the 
involvement of the glandular element, there will be brought about 
a condition which is one of atrophy due to pressure. Such con- 
dition will be described under Atrophic Pharyngitis. While this 
pathological finding will vary according to the different causes 
found associated, and while its progress may be more rapid in one 
instance than another, yet the actual pathological alteration is 
practically the same in all cases of chronic pharyngitis. There is, 
however, a condition in which there is an actual increase in the 
connective-tissue element, which partakes more of the nature of a 
hyperplasia. It is not truly hypertrophy, because there is no 



SIMPLE CHRONIC PHARYNGITIS. 563 

increase in the actual function of the membrane, rather a decrease ; 
yet in certain conditions, in which the general nutrition is good and 
in which there is present no constitutional diathesis or dyscrasia, 
the overgrowth of the tissue is a simple hyperplasia. In such 
conditions an atrophic process will not follow, and the only marked 
pathological alteration will be in the glandular elements that are 
subjected to pressure from the increase in the connective tissue, 
not however, from contraction. In all hyperplasia the nutrition 
is good. The very fact that the hyperplasia occurs, of necessity 
proves this. With this good nutrition, then, there will be kept 
up a fair amount of glandular secretion, and the condition will 
not progress to one in which the mucous membrane becomes dry 
and permits of accumulation of altered secretion on its surface. 

Symptoms. — The mucous membrane is either hyperemic or 
congested, but never uniformly so. There is a marked variation 
in color. The whole border of the pharyngeal structure is of a 
brighter color, while the actual pharyngeal structures tend more 
to the color produced by congestion. The palatine folds and the 
inferior and anterior margin of the soft palate is of a lighter red 
color, resembling more the blush of an acute inflammation. The 
pharyngeal surface may show congested capillaries and congested 
venules (Fig. 214). The surface is irregular and slightly nodular, 
not projecting so markedly as in the true follicular variety. A 
varicose condition of the vessels may also be observed at the base 
of the tongue — extending partially into the pillars of the fauces. 
This, however, is more marked in the varieties of chronic phar- 
yngitis in which the organized inflammatory connective tissue has 
gone on to actual contraction. The depressions in the pharyngeal 
structure will be filled with tenacious mucus, and at first appear- 
ance will resemble membranous inflammation very closely. When 
the condition is brought about in any of the forms of pneumono- 
koniosis the secretion is always colored, the color corresponding to 
the material which is responsible for the inflammatory process. 

The secretions are markedly altered in character, owing to 
the pathological changes which have taken place in the secreting 
gland-structure. As the case progresses, the secretions become more 
tenacious, with a tendency to become encrusted, resembling very 
much the condition in the nasal cavities in the beginning of atro- 
phic processes. The voice is usually affected, there being consid- 
erable hoarseness, and the patient seems to lose somewhat the con- 
trol of the muscles of phonation, causing a peculiar jerky voice. 
This condition, however, is not due to laryngeal alteration as much 
as it is to the alteration in the pharyngeal muscles, which causes, 
on attempt at phonation, a spasm of the pharynx. Besides, there 
may be some slight irritation of the superior laryngeal nerve, from 
the inflammatory condition, which extends by continuity of struct- 
ure to the tissue surrounding the vocal cords. There is a pecul- 
iar weakness of the voice, and the individual soon complains of 



564 DISEASES OF THE PHARYNX. 

" throat-tire," with a decided aching in the muscles of the throat. 
This aching sensation is relieved by the patient grasping the throat 
and supporting the muscles by slight pressure. In attempting to 
use the voice in singing, there is marked limitation of the register, 
with uncertainty of tone and inability to control the pitch of the 
voice, although the singer may be conscious that his voice is out 
of tune. The nasal respiration may not be markedly interfered 
with, unless there be complicated with the process enlargement of 
the gland-structure in the vault of the pharynx or in the faucial 
pillars, or associated obstructive lesions ; breathing is, however, 
often shallow and insufficient. The cough is irritable and rasping, 
and a constant desire on the part of the individual to clear the 
throat of mucus keeps up a continual hacking, which in itself is a 
source of unceasing irritation and productive of the exact condi- 
tion for which the physician is attempting to afford relief. Some- 
times the secretion may be slightly blood-streaked, which, although 
alarming to the patient, is rarely of any import, as associated with 
the pharyngeal inflammatory process there is usually the same 
condition present at the base of the tongue, in the periglottic 
structures, and from the constant effort to free the throat from 
secretion there may be rupture of dilated veins or overdistended 
capillaries or arterioles. There is a constant desire to swallow, 
which is brought about by the associated enlargement of the lin- 
gual tonsil and by the accumulated secretion in the pharyngeal 
structure just above the point that is cleared by the act of swal- 
lowing. The patient will complain of the sensation of a foreign 
body in the throat and afford some grounds for suspecting the con- 
dition described as "globus hystericus," as it will give rise to 
symptoms resembling very much this hysterical phenomenon. 
The pain on swallowing will vary with the extent of the inflam- 
mation and the degree of pathological alteration. As a rule, 
there is only slight pain on swallowing, except when taking 
warm fluids or food highly seasoned with pungent condiments. 
The sense of taste will be slightly affected if the process is lim- 
ited largely to the pharyngeal structures. However, if the nasal 
cavities and anterior pharynx are involved, there will be marked 
interference not only with taste, but also with the sense of smell. 
The same rule as to involvement can be applied to the Eustachian 
tubes and to the effect on hearing. After meals the secretions are 
always increased, and the patient is subjected to a paroxysmal fit of 
coughing and hacking, in which frothy and slightly colored mucus 
is expectorated. Inhalations of dust or sudden changes of tem- 
perature, as going from a warm room into a cold one, will also pro- 
duce paroxysmal cough. There is nearly always associated digestive 
disturbance. This may be, however, primary to the pharyngeal 
inflammation and associated directly as an etiological factor ; or it 
may be secondary, caused by irritation from the unconsciously 
swallowed secretion. There is frequently an accompanying 



SIMPLE CHRONIC PHARYNGITIS. 565 

laryngitis, which may be produced by an extension of the inflam- 
mation by continuity of structure ; but in the majority of cases it 
is due to "the same etiological factor producing the inflammation in 
the pharyngeal structures. 

Diagnosis. — Simple chronic pharyngitis as a condition is not 
difficult of diagnosis. However, as the prognosis and treatment 
of the condition depend entirely upon the causal factor, this can 
be attained only by careful clinical observations. 

Prognosis. — The prognosis depends entirely upon the correct 
recognition of the causal factor, as on this depends the success or 
failure of treatment. 

Treatment. — Careful attention should be given to the indi- 
vidual's general condition and to the correction, as far as possible, 
of any underlvinp; constitutional diathesis or organic lesion. There 
should be free stimulation of the glandular secretions of the ali- 
mentary and the urinary tract. For this purpose nothing is better 
than granular effervescing phosphate of sodium in from 1-dram to 
J-ounce doses, given in the morning or before each meal. Equally 
good is succinate of soda in 1 0- to 20-grain doses. For its tonic 
alterative effect, compound wine of iodin (Llewellyn's) — each dram 
of which contains \ grain of iodin, \ grain of bromin, and T ^ 
grain of phosphorus — should be administered three times daily 
after meals. It should be taken in a fourth of a glass of water. 
Locally, the membranes should be frequently and thoroughly 
cleansed by the use of sprays or gargles. For this purpose a 
gargle of plain hot water, at a temperature that can be comfortably 
borne, will generally give relief, besides being a local stimulant to 
the blood-supply. However, the secretion may be so tenacious as 
to require some dissolving solution. To accomplish this a spray 
or gargle of a strong salt solution or an alkaline wash of bicar- 
bonate of soda or bicarbonate of potash, 15 grains to the ounce of 
water, will usually suffice. However, in cases in which there is 
marked irritation a cleansing and sedative effect will be produced 
by the use of hot milk, to which has been added 10 grains of 
sodium chlorid to the ounce. If such irritation remains after the 
cleansing of the surface, a gargle of dilute hydrochloric acid, 10 to 
20 drops to the ounce of water, or a teaspoonful of camphorated tinct- 
ure of opium to an ounce of water, will afford relief. However, 
where there is marked engorgement of the blood-vessels, with per- 
manent thickening in the submucosa, as a result of inflammatory 
changes, gargles or sprays of any kind afford only temporary relief. 
If there is any irregularity in the upper respiratory tract in the 
form of nasal obstruction, which is acting as an exciting factor, 
such obstruction must be promptly removed. If the condition 
exists along with formation of the bony structure supporting the 
pharyngeal membrane, as in the slanting pharynx, or in the pecul- 
iar curved pharynx, permanent cure will rarely ever be accom- 
plished. In those cases in which the condition is brought about 



566 DISEASES OF THE PHARYNX. 

by misuse or overuse of the voice and the muscles of phonation, 
absolute rest must be insisted upon. Many cases of pharyngitis 
and laryngitis of this variety cannot merely be temporarily re- 
lieved, but even permanently cured by instruction in the proper 
methods of respiration and elocution. Where the condition is due 
to the effects of stimulants, as alcohol and tobacco, the use of such 
should be interdicted. Existing diatheses, as the rheumatic or 
gouty, which frequently are exciting factors, must receive prompt 
and energetic treatment. A change of climate is often beneficial, 
regardless of the exciting cause. 

SUBACUTE PHARYNGITIS. 

A subacute inflammatory condition of the pharyngeal mucous 
membrane is not a special disease. It is, in reality, the late stage 
of an acute pharyngitis in which there has been neglect of treat- 
ment, or in which the condition has failed to respond to treatment. 
The symptoms and pathology are identical w T ith the late stage of 
the acute condition or the early stage of the chronic. It is the 
intermediate process, when the permanent structural alterations 
are just beginning to take place and reach that point in which 
there is less likelihood of its return to the normal. The remedial 
agents as described under Simple Chronic Pharyngitis should be 
employed, as indicated by the symptoms present. 

FOLLICULAR PHARYNGITIS. 

Synonyms. — Clergyman's sore throat ; Dysphonia clericorum ; 
Folliculous pharyngitis ; Granular pharyngitis. 

Definition. — A chronic inflammatory condition of the phar- 
yngeal mucosa, especially involving glandular structure. It is 
characterized by an altered secretion and by irritation of the 
pharynx, accompanied frequently by a sharp, hacking cough. 
Alteration of the voice is a constant symptom, varying under 
different circumstances from a slight hoarseness to * complete 
aphonia. The membrane presents a characteristic appearance, 
with more or less general congestion and a surface studded with 
small reddish or yellowish elevations, either discrete or coalesced, 
and caused by the inflamed and distended glands. If these have 
discharged their contents, small patches of a thick whitish or yel- 
lowish material may be seen closely adherent to the elevations. 

Etiology. — Predisposing- Causes. — In this connection must 
again be cited the general conditions already mentioned as favoring 
chronic inflammatory processes in the mucous membrane of the 
respiratory tract. The young and middle-aged are more liable 
to its occurrence than those of elderly life, and males, possibly 
because of more exposed life, are more often affected than females. 
Here again the scrofulous, rheumatic, gouty, and anemic diatheses, 



FOLLICULAR PHARYNGITIS. 567 

as well as generally lowered tone of the bodily organ, are of im- 
portance as predisposing conditions. The same is true of the con- 
dition of the mucous membrane following the infectious diseases, 
such as measles, scarlet fever, and the like. The neurotic tem- 
perament, whether inherited or acquired through excessive 
nervous strain, as from overwork, mental or physical, improper 
stimulating diet, the demands of social duties, and a host of other 
causes, are favorable to the establishment of the condition. JSor 
must the influence of the various gastric and hepatic disorders, as 
well as conditions tending to cause a venous congestion of the sub- 
mucosa, be overlooked. Certain local conditions are extremely 
likely to be attended with this pharyngeal involvement. These 
include chronic rhinitis, nasopharyngitis, the various obstructive 
lesions of the nasal cavities, and conditions of the anterior and 
posterior cavities attended by irritant discharges which more or 
less constantly are brought into contact with the loAver membrane. 
In fact, frequently the symptoms assigned to follicular pharyngitis 
may be almost entirely due to irritation in the nasopharynx. The 
fact that many of the cases occur with such inflammatory processes 
accounts for many of the distressing throat-symptoms which are 
referred from the nasopharynx and not entirely due to the enlarged 
follicle to which these symptoms are often attributed. Climatic 
conditions are of importance, as is the constant inhalation of vari- 
ous substances of irritating action. In the latter connection the 
habitual use of tobacco has been the subject of much discussion ; 
to say the least, however, it cannot be regarded as a prophylactic 
against the occurrence of the condition, nor as a palliative of it 
when once established. The influence of occupation is a most 
important one, those who are compelled by their vocation to use 
their vocal apparatus under many and varied unfavorable condi- 
tions being especially liable to the acquirement of the malady. 
Thus, it is peculiarly a disease of clergymen, who in addition to 
their Sunday services are taxed by other public demands ; of law- 
yers with practices necessitating long and fatiguing pleas in dusty 
and ill- ventilated court-rooms ; of campaign speakers ; actors ; 
singers, and of those in the host of minor callings, such as hucksters 
and auctioneers. The condition is but another phase of simple 
chronic pharyngitis. Repeated attacks of acute pharyngitis are 
liable to create the condition, either from frequent repetition or 
prolongation of a severe attack. 

Exciting- Causes. — The overuse of the voice — the " straining 
of the voice/' as it is popularly termed — is among the most impor- 
tant of these. This may be active in several ways. Prolonged 
and repeated use of the voice, repeated efforts to attain and main- 
tain either extreme of the singing register, as in opera singers, and 
the taxing of the vocal apparatus in loud, high-keyed speaking are 
the usual examples. In many cases improper vocalization during 
such efforts is an additional source of irritation, for the lips, teeth, 



568 DISEASES OF THE PHARYNX. 

tongue, etc., are not made to perform their functions fully, which 
to a certain extent causes increased effort on the part of the pharyn- 
geal structure. It may be that the use of the voice in itself is not 
sufficient to have a determinant effect, but coupled with an exist- 
ing irritation, as in acute catarrh, a dusty or smoky atmosphere, or 
other unfavorable condition, it is sufficient to establish it. Exposure 
to a variable climate and the various other agencies which, sepa- 
rately or combined, act in the causation of colds are prolific of the 
condition. The habitual taking of hot, pungent foods, solid and 
liquid, as well as the inhalation of irritants, especially those over- 
stimulating to the glandular structures, are undoubtedly active 
causes in many cases. In some cases there apparently exists a 
liability to its occurrence, in which no definite causative factor 
can be ascertained. 

Pathology. — The pathology of this condition does not differ, 
as regards the membrane in general, from that of any simple 
chronic catarrhal condition. There is the same submucous infil- 
tration of fluid with proliferation or retrogression of cells. The 
vascular tone is below normal, and the vessel-walls are relaxed 
and usually, especially the veins, distended. The surface-epithe- 
lium is swollen and desquamating, and the surface is more or less 
covered by a .thick secretion intimately admixed with cellular 
elements and debris. In certain areas the inflammatory prolifera- 
tion may have organized in fibrous tissue, forming a so-called 
hypertrophic change. Or possibly, if the condition is of sufficient 
chronicity, these may have contracted into areas of atrophic char- 
acter. The peculiarity, however, of the condition, both clinically 
and pathologically, consists in the glandular phenomena. The 
primary function of the glands is, of course, the secretion of mucus, 
and normally the law of supply and demand is as operative here 
as elsewhere. Increased demand in the shape of suitable stimuli 
from without or within is followed by increased secretion. If, 
however, this stimulation be sufficiently repeated or prolonged, in 
short, of exactly such a character as we have already considered 
in this connection, the functional activity of the glands is exhausted, 
and they, with their immediately adjacent tissue, become inflamed 
and practically form encysted foreign bodies. This explains the 
excessive action of the voice in producing the affection, since it 
calls for increased secretion to supply sufficient lubrication, thus 
overtaxing the glands and resulting in their inflammation. The 
same is true of the other causes mentioned. Macroscopically, the 
affected structures present themselves as small elevations, from one 
to several pin-heads in size, reddish or lighter in hue (Fig. 214). 
They may be scattered or coalesce (Fig. 215), be few or many. This 
swelling is due partly to the inflammation in the periglandular 
tissue and partly to the increasing distention of the gland-cavity 
through the occlusion of its orifice. If, however, the follicle be 
seen at a later stage, it may possibly have ruptured, and its apex 



mj 







Fig. 214.— Follicular pharyngitis with adhesion of pillars to faucial tonsil. 



Fig. 215.— Large follicle on pharyngeal wall. Dilated vessels with enlarged and adherent 

tonsils. 



FOLLICULAR PHARYNGITIS. 569 

or the apices of the associated follicles, which may also have dis- 
charged their contents, are . covered by a thick, pasty, cheesy and 
foul, light-colored mass. This is the so-called exudative form, as 
contrasted with the other or simple chronic variety. Microscopi- 
cally, there are in the tissue adjacent to the glands the usual 
inflammatory phenomena. The orifices of the glands are seen to 
be occluded, either by inflammatory swelling, by impacted cell- 
masses, or by inspissated secretion. The caliber of the glands or 
their efferent ducts are enlarged. The lining epithelium is swollen, 
and the constituent cells are in various stages of fatty degener- 
ation. There is an abundant desquamation, and the gland-cavities 
are filled with detached cells, whole or disintegrating, by granular 
debris, and by fat-globules from the broken-down cells. There 
is more or less fluid present, the absorption of which leads later 
to the caseation of the intraglandular masses. This condition may 
persist, the whole forming practically a foreign body embedded in 
the membrane and adding to the irritation. Or the gland-contents 
may find exit either through a minute opening of the obstructed 
outlet or by rupture, and the cheesy mass may slowly exude 
and cover the surface with a foul, ill-smelling coat. In some cases 
calcareous deposition has taken place in the mass, and concretions 
of varied shape have been the resultant effect. The condition is 
frequently associated with adhesion of the faucial pillars to the 
tonsil, as seen in Fig. 187. 

Symptoms. — The establishment of the condition proper is 
generally preceded by either repeated or prolonged acute inflam- 
mation of the pharynx or a chronic condition of the same charac- 
ter. The direct onset is usually not rapid. In its incipiency the 
glandular structures may respond to the stimulus present and 
cause a profuse outpouring of secretion, the patient being unable 
to use his voice properly because of the constant filling of the 
mouth with fluid. This is, however, soon abated, and the true 
nature of the trouble appears. The overtaxed glands inflame, and 
the secretion proportionately lessens and deteriorates. The patient 
notices a dry, uneasy feeling in the throat, especially after use of 
the voice. This may last but a short time, only to return again 
more severely upon a second irritation. The attacks grow longer 
in duration and severer in character with each succeeding expos- 
ure. The feeling of throat-uneasiness gradually intensifying, 
perhaps after a few weeks, even months, and not unfrequently a 
year or so, runs into a persistent feeling of weariness as the per- 
manency of the condition becomes assured. The voice, on the 
slightest use beyond a limit peculiar to each case, becomes hoarse 
and muffled, its quality is altered, and it may fall to a mere harsh 
whisper or even complete aphonia, Following its use, especially 
if at all prolonged, the uneasy feeling intensifies, the throat is 
" tired," and may even become acutely painful. Speech may 
become slow and hesitating from the pain and soreness produced 



570 DISEASES OF THE PHARYNX. 

by the use of the voice. In cases of long standing, pain is apt to 
develop as a more or less constant symptom, usually of a burning, 
pricking, or stinging character, not unlike and frequently described 
by the patient as resembling a fish-bone or other sharp foreign 
body lodged within the pharyngeal limits. It may be of a dull, 
aching character, and the irritation in the pharynx may be intensi- 
fied by deglutition, causing a feeling of rawness or soreness on 
swallowing. The secretion resembles that of a simple chronic 
pharyngitis, and its quantity is influenced to no small extent by 
the number of the glands involved. Early in the course of the 
malady it becomes thick and glairy, but is usually clear ; later it 
becomes more or less mucopurulent, and finally may even tend to 
crust-formation. It is scanty in quantity, and causes a constant 
effort on the part of the patient to remove it. The effort to clear 
the throat may for a brief moment give some relief, and any 
hoarseness of voice may temporarily disappear. Soon, however, 
the condition redevelops, or in not a few cases no relief at all is 
obtained, and the expectoration, if any, is scanty and may possibly 
be blood-streaked. Cough is a troublesome symptom, usually 
sharp, barking, or metallic, either practically constant or occurring 
in paroxysms, and a severe attack is more than apt to produce 
soreness and aching in the throat and region of the soft palate. It 
is due undoubtedly to several causes, such as irritant secretion, the 
general irritability of the pharyngeal mucosa, and the " tickling " 
produced by a relaxed uvula. In some few instances the cough 
has apparently been replaced by asthma of a mild or rather severe 
type. In long-standing cases the inflammatory process may extend 
to the nasal, lower pharyngeal, and laryngeal regions, and excite 
acute or chronic manifestations there, with varied associated de- 
rangements, such as impairment of hearing, smell, and taste. 
Constitutionally, there is a great variance in different cases. There 
may be little or no impairment of the general health, though some 
lowering of the bodily vigor, possibly even of grave import, is apt 
to be present. The predisposing diathesis may be noticed in 
greater or less marked degree. Gastric and intestinal derange- 
ments are of very common occurrence, acting in some cases possi- 
bly as a cause, in others as an effect, and explanatory, no doubt, of 
many of the skin-eruptions that have been noted from time to time 
as accompanying the pharyngeal condition. Mental dulness is not 
impossibly an occasional development. Inspection shows a char- 
acteristic condition of the pharyngeal membrane. The surface 
displays a number of elevations varying in size, reddish or 
reddish-yellow in hue, which stand out from the surface (Fig. 
214). These may be scattered, grouped in small collections, or 
form large elevated areas. Not uncommonly there is associated a 
band-like thickening behind the posterior half-arches, forming the 
so-called 'pharyngitis hypertrophica lateralis. If the process is 



FOLLICULAR PHARYNGITIS. 571 

further advanced, the small irregular patches of cheesy material 
may be seen adherent to the apices, more abundant possibly in the 
anterior region than on the posterior wall. Between and surround- 
ing the follicular groups may be seen the dilated vessels (Fig. 214) 
forming a rather complex network. The membrane is partially 
or more generally congested. In long-standing cases the whole 
membrane may be relaxed, the uvula and soft palate be flabby 
and toneless, and the base of the tongue involved. In some cases 
there may be quite an extensive involvement of the follicles with- 
out the production of any marked subjective symptoms. 

Diagnosis. — This is usually not of great difficulty. The 
characteristic symptom is, of course, the presence of the enlarged 
follicles, as revealed by inspection. The history of the case, the 
voice-phenomena, the peculiar throat-symptoms, and the occupa- 
tion of the patient are to be taken into account. 

Prognosis. — The disease is not dangerous to life, and can 
usually be relieved by systematic and long-continued treatment. 
It has, however, an important bearing on the development of 
laryngeal and nasopharyngeal troubles. 

Treatment. — The treatment should be, first, careful attention 
to the general health of the patient ; and second, local treatment 
of the follicles and engorged vessels. The constitutional treatment 
must depend entirely on the clinical indications presented by 
the patient, and must be determined by the practitioner. In the 
early or acute stage, where permanent structure-change has not 
taken place, I have obtained excellent results from the adminis- 
tration of drugs which are eliminated by the mucous membrane. 
The following should be administered three times daily : 

]$. Phosphori, gr. -^ (0.0006) ; 

Iodini, 

Bromini, da gr. f-J- (0.008-0.01) ; 
Vini Xerici, fl3j (4.0).— M. 

The distressing cough and constant irritation can be relieved 
by the administration of codein, in doses of -^ to \ of a grain, 
three or four times daily, or a dram of camphorated tincture of 
opium to an ounce of water as a gargle. As to the treatment of 
the actual follicle, each follicle may be touched with a 20 per cent, 
chromic-acid solution or the dilute hydrochloric acid. This can 
be done without contact to the surrounding structure, if a fine- 
pointed applicator is used, on the point of which is tightly wrapped 
a small portion of absorbent cotton ; the cotton is saturated with 
the solution, the excess dried off with another piece of cotton, 
and then applied directly to the follicle, using very little pressure. 
Equally beneficial results may be obtained by the mopping of the 
entire surface with — 



572 DISEASES OF THE PHARYNX. 

1^. Olei pini sylvestris, 

Olei eucalypti, da gtt. v (.3) ; 
Menthol (crystals), gr. iv (.24) ; 

Tincturse benzoini, flaj (30.).— M. 

This should be applied every other day for its stimulating 
effect and tendency to promote resolution by absorption. In more 
obstinate cases, the simple puncturing of the follicle by means of a 
sharp-pointed applicator or probe is sufficient. The probe should 
be bluntly needle-pointed and with no cutting surface. Relief of 
the engorged vessels may be obtained in the same way, or the 
patient should be instructed to gargle the throat frequently with 
water as hot as can be comfortably borne. This is especially bene- 
ficial in the variety where several follicles coalesce and form blebs 
(Fig. 215). This, through its local stimulation to circulation, does 
much toward re-establishing the normal function of the gland by 
relieving congestion. In many cases the above procedure will 
give permanent relief. Should the condition be chronic, with 
fixed tissue-alteration, the application of the galvanocautery is 
warranted. The needle should be fine-pointed and heated to a 
white heat, and should be applied directly to the follicle, care being 
taken not to penetrate too deeply into the tissue and not to involve 
the healthy surrounding structure. I have seen cases in which a 
great number of follicles had been removed by the galvanocau- 
tery several years previously, in which the condition of the pharynx, 
brought about by the extensive and possibly careless cauterization, 
was much worse than that originally produced by the follicular 
pharyngitis. When follicular pharyngitis occurs along with naso- 
pharyngeal catarrh, treatment for the associated condition should 
be instituted. 

While the excessive use of tobacco and alcohol may not be 
direct causal factors, yet they may aggravate the condition, and 
their use should be prohibited. 

HYPERPLASTIC CHANGE IN THE PHARYNGEAL STRUCTURE. 

Occasionally there is seen in the lateral walls of the pharynx a 
thickened condition involving the mucous membrane and under- 
lying structures. There seems to be no tendency to contraction, 
and the pathological alteration is apparently an overgrowth of the 
connective-tissue elements similar to that of a benign tumor — in 
reality, a hyperplasia. It rarely ever involves the actual pharyn- 
geal structure, and, owing to the fact that it is usually lateral, has 
been described in various works as Pharyngitis hypertrophica 
lateralis. This condition should not be confused with Glandular 
Pharyngitis lateralis. It seems to be associated with chronic in- 
flammatory processes in adjacent structure. As the condition is 
usually found occurring with chronic nasopharyngeal inflammation, 



ATROPHIC PHARYNGITIS. 573 

especially that involving the portion back of the soft pillars, it 
seems to be rather an extension of the chronic inflammatory 
process by continuity ; or while not, in reality, an inflammatory 
process, the increase of the connective-tissue element may be ex- 
plained by the increased nutrition brought about through the in- 
flammatory process situated above, as the hyperplastic structure 
is in the direct line of the vascular supply as well as in direct 
line as to continuity of structure. The hyperplastic change which 
occurs in tertiary syphilis is described on page 592. 

ATROPHIC PHARYNGITIS. 

Synonyms. — Dry pharyngitis ; Pharyngitis sicca. 

Atrophic pharyngitis is in reality not an inflammatory process, 
but the resulting permanent pathological alteration in the mucous 
membranes of the pharynx. 

Etiology. — Although the causes of atrophic pharyngitis may 
be different, the histological and physiological changes of the 
mucous membrane of the pharynx are practically the same, regard- 
less of cause. Any condition that will bring about a chronic 
inflammatory process, such as local irritation, as observed in indi- 
viduals whose occupation subjects them to constant exposure to the 
inhalation of dust, irritating fumes or vapors, or involvement of 
the pharynx by a continuation of inflammatory processes from 
adjacent structure produces a permanent thickening of the sub- 
mucosa with organization and contraction. By the contraction of 
the inflammatory organized tissue the muciparous glands of the 
mucous membrane are involved and their functional activity 
altered, or the gland may be even entirely obliterated. This gives 
rise to perverted secretion on the surface, with a tendency to 
accumulation of material which in itself is a constant source of 
irritation. Such would be the variety of atrophic pharyngitis that 
would follow any chronic inflammatory process. 

Again, in any constitutional condition in which there is inter- 
ference with the systemic circulation and damming back of the 
blood in any part from venous stasis of the dilated blood-vessels, 
through pressure and poor nutrition there may be brought about an 
atrophic process. Although the appearance of the membrane is 
•somewhat different, yet it is as truly atrophic, as regards function 
and loss of actual cellular structure, as the first variety. 

Or a simple atrophy may result from trophic lesions. The 
etiology may be obscure, nevertheless the simple atrophic process 
takes place in the mucous membrane and brings about, as far as 
function is concerned, an alteration similar to that due to contrac- 
tion of inflammatory tissue. 

There is a variety, however, of dry pharyngitis which is not 
atrophic, that is due to some constitutional disease in which there 
is an alteration in the general nutrition, and the glandular secretion 



574 DISEASES OF TEE PHARYNX. 

is modified as to its chemical constituents. When such a condition 
arises, the normal secretion poured out on the pharyngeal surface 
tends to adhere, and the surface becomes glazed and looks as if 
it had been coated with a thin layer of varnish or shellac. In 
such cases there is very little actual alteration in the mucous-mem- 
brane structure, and the condition is one of perverted secretion 
rather than pathological alteration in the structure. This has been 
observed in diabetes mellitus and in various forms of gastric and 
intestinal disorders. Atrophic rhinitis is given by many as a 
causal factor of atrophic pharyngitis. I am inclined to believe 
that the condition which would cause an atrophic rhinitis would 
also be responsible for the atrophic pharyngitis, although in some 
rare cases the inflammatory process travelling by continuity of 
structure, aided by gravity, may extend from the nasal and naso- 
pharyngeal cavities to the pharynx and even to the larynx. In 
the majority of cases, however, instead of spreading by continuity, 
it is an association of cause that produces both conditions. Nasal 
obstruction, however, is an important factor in certain forms of 
dry pharyngitis. When the nasal obstruction is sufficient to cause 
mouth-breathing, the pharyngeal mucous membrane is irritated by 
the inhalation of air which is neither moistened, freed from dust, 
nor subjected to the proper thermal changes — in other words, which 
has not been subjected to the physiological action as afforded by the 
nasal mucosa. This in itself may produce dry pharyngitis, and in 
turn a simple chronic pharyngitis, and then by inflammatory or- 
ganization and fibrous contraction there is produced a true atrophic 
condition. As a rule, then, excluding the simple atrophy of ner- 
vous origin, the varieties of dry and atrophic pharyngitis are sec- 
ondary and a result of local or constitutional causes. 

Pathology. — In the simple dry variety, in which the surface 
of the pharynx is coated with a thin, glairy mucus, which har- 
dens and dries on the surface, the pathological alteration while 
in that stage is largely one limited to secretion, in which the 
chemical constituents of the normal secretion are markedly altered, 
due to some constitutional dyscrasia. This secretion in itself, by 
local irritation, may bring about chronic inflammation in which 
there is leukocyte migration and fixed connective-tissue cell-prolif- 
eration in the submucosa, and with the supplied nutrition capillary 
budding will take place, the origin of inflammatory tissue. This, 
by excess of tissue, will produce some pressure ; but by complete 
organization there is contraction of the inflammatory tissue, which 
is now practically scar-tissue, and the inflammatory process no 
longer existing, there is brought about an atrophic process, which 
is one of pressure. This contracting tissue effects the partial 
obliteration of the blood-supply, and also produces pressure upon 
the secreting glands, with interference in their secretion and their 
final obliteration. The pathological alterations brought about by 



ATROPHIC PHARYNGITIS. 575 

vascular changes, as noted in circulatory interference, are seen in 
lesions of the heart, lung, liver, kidney, or intestine, in which 
there is damming back of the venous circulation. From this 
cyanotic condition of the mucous membrane there is interference 
with nutrition as well as pressure on the perivascular tissue from 
the overdistended vessels. This will also include the gland-struct- 
ure of the part. If this condition is kept up sufficiently long, 
although slight inflammatory changes may take place early, it 
must eventually result as a pressure atrophy ; and, unless the 
cause is removed before this permanent alteration has taken place 
in the tissue, the change will be a permanent one. Bacteriolog- 
ical examination shows that there is no special organism which 
plays an important part as an etiological factor. From my own 
investigations I believe that the majority of bacteria present are 
secondary, and the fact that various pathogenic germs were found 
present, such as the Staphylococcus and Streptococcus pyogenes 
and the Klebs-Loffler bacillus, does not prove that they were in 
any way associated as causal factors, and in many cases animal 
experimentation shows these bacteria to be non-virulent. There 
is also present a large number of saprophytic bacteria, which are 
in themselves non-pathogenic. 

Symptoms. — The prominent symptom of atrophic pharyn- 
gitis is a burning, itching sensation in the throat, with intolerable 
dryness. Swallowing is difficult, it being almost impossible to 
swallow solid food unless the pharyngeal surface is first moistened. 
There is a certain amount of rigidity and stiffness about the throat. 
Occasionally the dried mucus on the surface will be so firm that 
on friction with the probe or the tip of the tongue-depressor a dis- 
tinct grating can be heard. The character of the secretion will 
depend entirely upon the variety of change and the stage. In 
the simple dry pharyngitis, in which the alteration in the structure 
below is very slight, the membrane is thin, almost transparent, at 
least translucent, and the surface smooth. However, as the change 
in the glandular and submucous structure advances, the secretion 
will become thicker, more w r rinkled, and accumulated in masses, 
and will be colored brown or green. There is a hacking, rasping 
cough, not relieved by expectoration, with the sensation of a for- 
eign body in the throat. There is usually associated w T ith the 
pharyngeal alteration a similar condition in the nasopharynx and 
nasal cavities, so that the accumulated secretion usually extends 
up into the nasopharynx, with frequent simultaneous involvement 
of the Eustachian tube. In the dry variety, or in the early stage 
of the atrophic process, on removal of the tenacious secretion the 
underlying mucous-membrane surface will be reddened and ex- 
tremely sensitive. However, as the process advances and the 
secretions become more tenacious and tend to accumulate in crusts, 
on removal the surface will present irregularly colored areas, some 



576 DISEASES OF THE PHARYNX. 

spots being markedly inflamed, while others are pale and colorless. 
The membrane will seem thinner than normal. This is true 
except in the variety in which the atrophic change is due to 
venous stasis and pressure-atrophy. The surface will then be 
more nodular, vessels will be seen coursing over the surface, 
and the secretions will not accumulate in crusts or masses, at least 
not early in the process ; but when the atrophic process is far 
advanced, such crustation may take place. The breath is usually 
heavy and the odor fetid, as the condition usually exists along 
with an atrophic rhinitis. 

Diagnosis. — The diagnosis is easily made, simple inspection 
being sufficient. However, the prognosis and treatment depend 
entirely on the underlying cause, which may not be so easily ascer- 
tained. Dryness of the throat may be a symptom in certain infec- 
tious fevers, but the associated phenomena will make the diagnosis 
easy. 

Prognosis. — In the simple dry variety the prognosis is good. 
In the early stage of the atrophic variety from contraction prog- 
nosis is also good ; but when the atrophic process has advanced, 
with permanent alteration in the structure, the outlook is not so 
favorable. The same can be said of the variety due to cyanotic 
congestion, unless the cause of the cyanosis can be removed before 
permanent alteration in the tissues occurs. 

Treatment. — As the condition is, in reality, not an inflamma- 
tory process, but a pathological alteration produced in the mucous 
membrane secondary to such processes, and necessarily involves a 
number of causative elements, this contraction involves the sub- 
mucosa and the muciparous glands as well as the epithelial layer. 
Upon the amount of fibrous tissue and the alteration produced in 
the structure involved in the contraction, as well as the extent of 
the area involved, will depend the prognosis as to palliation or 
cure ; for, if the process is well advanced, no amount of local or 
constitutional treatment will alter the already formed fibrous tissue 
or arrest its contraction. 

The process may be limited to the pharynx, or it may be sub- 
sequent to the same condition pre-existing in the anterior nasal 
cavity and nasopharynx ; when such is the case, the morbid proc- 
ess involving the true pharyngeal surface is somewhat different, 
and is more amenable to treatment than when secondary to local- 
ized inflammatory conditions of the pharynx. This is true for 
the following reasons : The condition is brought about by mechan- 
ical irritation, instead of spreading by continuity of tissue from 
the nasal mucous membrane. With atrophy of the mucous mem- 
branes of the nasal cavities there is marked enlargement of the 
space for the transmission of air. This allows an increased vol- 
ume of air to pass through the nasal cavities. Owing to the 
altered condition of the membrane, even the normal amount of 



ATROPHIC PHARYNGITIS. 577 

air would not be physiologically altered in temperature and 
moisture, much less the increased volume. This in itself would 
act as an irritation to the pharyngeal wall. The ciliated epi- 
thelium has also lost its function, owing to the atrophic process 
of the nasal mucous membrane ; therefore the particles of 
dust carried in by the air, instead of lodging and being expelled, 
pass directly into the nasopharynx and pharynx. The fact that 
such cases are more amenable to treatment does not depend so 
much upon the structural alteration of the tissue as it does upon 
the fact that the pre-existing condition in the anterior nares and 
nasopharynx directs attention to the pharynx proper, and treat- 
ment can be instituted early. 

The varieties of dry pharyngitis due to other causes present 
the same appearance clinically, but differ very much in their 
structural alteration. For instance, in dry pharyngitis due to cer- 
tain fumes or vapors the change is limited, at least for some 
considerable time, to the epithelial layer, and the discontinuance 
of exposure to such fumes will usually promote a rapid recovery. 
The variety seen in diabetes mellitus also presents very little 
structural change, and requires no separate treatment other than that 
directed toward the relief of the special disease. A mild variety 
of dry pharyngitis may be induced by nasal obstruction causing 
mouth-breathing. The treatment is obvious ; remove the nasal 
obstruction. If this should be done early, before any structural 
change has taken place in the pharyngeal tissue, the irritated mem- 
brane will rapidly return to normal ; but should the obstruction be 
of long standing, the condition of the pharyngeal tissue will be 
that induced by any chronic inflammatory process. 

It has been my own experience that solutions used by the 
patient rarely cleanse the membrane. While the patient should 
be given a solution for this purpose, to use two or three times 
daily, to ensure perfect cleansing he should be seen by the attend- 
ing physician at least every other day, or better daily, and the 
dried secretion be thoroughly removed, preferably by swabbing 
the entire surface with hydrogen peroxid and cinnamon water, in 
equal parts, followed by an alkaline wash, such as — 

ty. Sodii bicarbonatis, 
Sodii biboratis, 
Sodii chloratis, 

Potassii bicarbonatis, da gr. xv (1.0) ; 

Aquae, flgij (60.0).— M. 

This solution should be as hot as can be borne by the patient. 
The membrane should be thoroughly dried by pledgets of absorb- 
ent cotton carefully mopped over the surface, and a mild, stimula- 
ting solution applied. For the local stimulation, \ to 1 drop of 

37 



578 DISEASES OF THE PHARYNX. 

oil of mustard, or 2 drops of oil of cassia to an ounce of albolene 
or liquid vaselin, applied every other day directly to the diseased 
surface, is the best agent. Equally good results can be obtained 
by using, after cleansing and drying the membrane, pledgets of 
cotton saturated with an ointment of ichthyol and lanolin, equal 
parts, the pledgets being placed far back in the nostril, so that the 
solution will come in contact with the nasopharyngeal surface, and 
should be allowed to remain from fifteen to thirty minutes, or until 
there is marked stimulation of the membrane. 

The application of crude petroleum in the same manner, as 
well as the thorough mopping of the entire pharyngeal surface, is 
highly beneficial. 

The object of such applications is to produce merely a hyper- 
emia of the vessels, and care must be taken not to set up too 
violent irritation, or the resulting inflammatory condition will 
entirely offset the benefits of stimulation. Even after the most 
thorough cleansing of the membrane there is a tendency to the 
rapid accumulation of the altered secretion, and for the relief of 
the distressing symptoms caused by this accumulation there should 
be prescribed for the patient an oily preparation, which not only 
lubricates the parts, but also softens the secretion. The following 
formula will produce the desired effect : 

1^. Olei gaultherise, gtt. j (.06) ; 

Menthol, gr. v-x (0.3-0.6) ; 

Alboleni, vel 

Yaselini (liquid), flgj (30.0).— M. 

In the cases in which the change in the pharyngeal structure is an 
inflammatory one, there is no local application which will afford 
more relief for the distressing symptoms, besides being markedly 
useful in stimulating any remaining structure in which partial func- 
tion is still preserved, than refined or, better, crude petroleum. The 
patient can be instructed in the method of applying the oil, which 
should be done twice daily. In a number of apparently almost 
hopeless cases, in which this treatment was continued for a period 
extending over from six to ten months, almost permanent relief was 
obtained. After thoroughly removing the accumulated and dried 
secretion, benefit may be derived from mere massage of the mucous 
membrane. This can be accomplished by rubbing the surface 
with cotton or sponge. In some few cases of the simple atrophic 
variety the mild faradic current has been beneficial. The appli- 
cation of drugs by cataphoresis I have not found so satisfactory 
in the pharyngeal structure as in the nasal and laryngeal tissues. 

While the fibrous tissue cannot be altered or caused to return 
to the normal and a permanent cure effected, yet to the patient 
the relief of his distressing symptoms is the object sought. 



CYANOTIC PHARYNGITIS. 579 

The special constitutional treatment should consist in the ad- 
ministration of drugs which directly affect glandular secretion 
and are at least partially eliminated by the mucous membranes. 
In the general treatment, it is well to give some drug that will 
ensure the regular and free movements of the bowels, not so much 
by its purgative action as by its stimulation of glandular secretion. 
For this purpose the phosphate of soda should be given in from 
2- to 4-dram doses, in the form of the granular effervescing pow- 
der, twice or thrice daily, the frequency and size of the dose 
depending upon the therapeutic effect and the clinical indications. 
Sulphur waters are helpful adjuvants. The iodids, in the form of 
iodid of potassium and sodium, or benzoate of sodium, from their 
therapeutic action on glandular secretion, are unquestionably indi- 
cated and beneficial, out the long-continued use of these drugs 
produces gastric irritation. 

The arsenical preparations, however, are equally efficacious as 
remedial agents, and, owing to their lessened tendency to produce 
gastric irritation, are preferable. The best results will be obtained 
by the administration of from gr. 2V to gr. -^ of the double sul- 
phid of arsenic, given in pill form three times daily after meals. 



CYANOTIC PHARYNGITIS. 

This condition may be acute or chronic. If the cause of the 
cyanosis is continued a sufficient length of time, permanent patho- 
logical alteration of the structure will take place. 

Etiology and Pathology. — The etiology and pathology of 
this condition, involving the mucous membrane of the upper re- 
spiratory tract, is practically the same as chronic edematous rhini- 
tis, and the reader is referred to page 144. There are, however, a 
few personal observations I have made which are of sufficient 
import to be added under this chapter. 

It is a well-known fact that high altitudes affect circulatory con- 
ditions, and that there is a tendency to congestion or turgescence of 
the mucous membrane of the respiratory tract in certain individ- 
uals when subjected to high altitude. This circulatory change may 
manifest itself in the pharynx and produce a passive congestion 
or cyanotic condition, without inflammatory phenomena. There 
will be a hoarseness of the voice, owing to the congestion of the 
tissues about the cords, and also a sensation of fulness in the 
throat and an irritating cough, with only slight expectoration. 
Also, at these high altitudes the individual frequently has to drink 
snow-water, or at least the mountain-stream water, which is 
nothing more than melted snow. In my own experience, in an 
altitude of over 11,000 feet, where I camped for several weeks, I 
found none of the party influenced particularly by the altitude, 
except the sensation of fulness in the throat, with the peculiar dry- 



580 DISEASES OF THE PHARYNX. 

ness of the throat, but the drinking of the snow-water occasionally 
caused considerable irritation of the pharyngeal mucous membrane. 
However, if the water was boiled and then allowed to stand and 
cool to a temperature of a little above freezing, no bad effects were 
noticed. 

It is a well-known fact that persons who have to eat snow to 
quench their thirst frequently suffer from acute pharyngitis. It is 
also quite common to see cyanosis of the mucous membrane in indi- 
viduals who have any heart lesions and who ascend to a high 
altitude. 

As we all know, the circulation of the pharynx, both lymphatic 
and vascular, is an index to the individuals susceptibility both to 
internal and external influences, and I am inclined to think that 
these cases are nothing more than the inability of the respiration 
and circulation of the individual to so suddenly adjust themselves ; 
also the local irritation of the excessively cold water acting as a 
local irritant causing congestion, aggravated by the cold water. 

It has also been observed (and personally I have seen a few 
such cases) that individuals who are not native of the tropical 
regions, but who of necessity or desire visit those climates, are 
liable to a peculiar lesion of the mucous membrane of the phar- 
ynx or larynx, not so marked in the nasal or nasopharyngeal 
mucosa. The mucous membrane becomes relaxed and boggy, not 
inflammatory or congested, but simply relaxed and hangs in folds. 
This, I presume, is due to the change of climatic conditions 
and temperature, and also due to the heat, and probably food and 
water. My own experience has been that such cases, on return- 
ing to their native climate, with a little care by way of stim- 
ulant to secretions and muscular tone, rapidly recover and have no 
lasting or permanent ill-effects. 

ACUTE RHEUMATIC PHARYNGITIS. 

Synonyms. — Rheumatic sore throat ; Rheumatic angina ; 
Gouty sore throat ; Lithemic pharyngitis. 

Definition. — An acute inflammatory process caused by the 
presence of an irritant in the blood, consisting of some form of 
the acid urates, which excites inflammatory processes in superficial 
structures, especially those concerned in secretion and elimination, 
the great vascularity of the pharynx rendering it particularly 
liable. 

Etiology. — The uric-acid diathesis manifests itself in a num- 
ber of forms. In any variety where there is an excess of uric 
acid in the system, there is produced in the secreting or glandular 
structures a certain amount of irritation. This is due to the fact 
that when an excess of elimination is demanded by the excretory 
organ, and the necessity of elimination is beyond the power of 



ACUTE RHEUMATIC PHARYNGITIS. 581 

function of that organ, as of the kidney, certain other mucous- 
membrane structures aid as eliminators. It is well known that 
uric acid in its various forms excites inflammatory reactions in 
the mucous membrane of the kidney, where it is in reality a local 
irritant. The same is true in the other mucous-membrane tracts. 
In that variety of uric-acid diathesis known as lithemia, in which 
there may not be an excess of uric acid in the urine, yet there 
is absorbed or retained in the system the product of nitrogenous 
metabolism, the local inflammatory process in the pharynx is most 
marked. As a rule, the constitutional symptoms of the uric-acid 
diathesis are present, but this is by no means constant. Frequently 
the individual may have the local manifestations not only in the 
pharyngeal, but also in the laryngeal, nasal, and gastro-intestinal 
tracts, without there being practically any constitutional symptoms. 
There may be a slight tendency to headache, or aching pains in 
the muscles, especially in the muscles of the neck, yet no pro- 
nounced or characteristic symptoms of the gouty or rheumatic 
condition. The exciting factor of the acute attack is usually 
exposure to cold and dampness, especially if associated with any 
lessened vitality of the individual. 

Pathology. — The pathological alterations in the acute attack 
are the same as in catarrhal inflammation, the hyperemic vessels 
passing on to congestion, the nasopharyngeal surfaces being cov- 
ered with hypersecretion and overelaboration of mucus. It must 
be remembered that it is only a local manifestation of a systemic 
condition, and that there primarily is no lesion of the mucous 
membrane except that which is forced upon it by the irritating 
effect of the uric acid in the blood. However, if this is continued, 
it may bring about permanent pathological alterations in the 
tissue, as described under the chronic variety. While there is 
some difference of opinion as to the exact nature of the uric-acid 
diathesis in gout, rheumatism, or lithemia, yet the clinical phe- 
nomena and the clinical alterations in the mucous membrane are 
practically the same, and the different reactions obtained are 
entirely dependent upon the chemical pathology of the fluids and 
tissues of the body. 

In rare instances extensive ulceration of the pharynx has 
occurred as a direct result of rheumatism. The ulceration is 
usually limited and circumscribed, rarely ever involving the entire 
pharyngeal surface, and is generally very small in size. 

Symptoms. — As a rule, the attack comes on suddenly and 
without any apparent cause known to the patient. It may be 
suddenly noticed while sitting in his room under the same sur- 
roundings and circumstances to which he has day after day been 
accustomed. The first symptom is a sensation of fulness and 
accumulation in the throat, with slight pain, which is increased on 
swallowing. There is also a constant desire to swallow, although 



582 DISEASES OF THE PHARYNX. 

the act is difficult, the throat having a rigid, stiff feeling, and is 
hot, dry, and irritated, or there may be a sudden increased flow 
of secretion. In either case there is a constant tendency to clear 
the throat. This in itself is a constant source of irritation. Each 
act of swallowing seems to produce a new localized spot of in- 
flammation, and the movements of the individual with a rheu- 
matic throat during the act of swallowing are almost characteristic, 
with each act the head assuming a different position. The attack 
may last from a few hours to several days and may be followed 
by acute exacerbations. It may be associated with modified sys- 
temic symptoms of rheumatism. As a rule, the adjacent mucous 
membranes are involved, although they may not be to the same 
extent as the pharyngeal structure. The attack may disappear as 
suddenly as it came. The pain is of a peculiar nature. It is 
decidedly superficial, and in attempting to clear the throat the 
sensation to the patient is as though the membrane were being 
pricked by a sharp-pointed instrument. There may be slight rise 
of temperature, but, as a rule, the patient is only inconvenienced 
by the soreness of his throat, and is able to go on with his occupa- 
tion. Frequently there will be a history of previous attacks, and 
the individual will have discovered that by exercising he can 
relieve the condition. That is easily explained by the fact that 
exercise increases elimination. If there is a history of many 
previous attacks by the irritating effect of the uric acid, some irri- 
tation will have been produced in the other mucous-membrane 
structures, and there may be associated with the acute exacerba- 
tions some gastric and intestinal disorders. 

Diagnosis. — The urinary examination will usually determine 
the diagnosis ; however, the suddenness of the attack, the lack of 
marked clinical symptoms, and the rheumatic history should be 
also considered. In the examination of the urine it must be 
remembered that deficiency in the amount of uric acid and the 
percentage of urea in the urine is of graver import than excessive 
amount. While the latter finding would show that the system 
was overcharged, it would also show that the elimination was good, 
and that the kidneys were rapidly ridding the system of the 
excess ; while a deficiency in amount would show a failure of 
elimination. Quite frequently, and especially is this true in the 
variety known as the lithemic sore throat, is this deficiency noted. 
My laboratory records positively confirm this statement. 

Prognosis. — The prognosis as regards permanent cure is 
good, providing prompt and efficient treatment for the correction 
of the uric-acid diathesis is instituted. 

Treatment. — The daily habits of the patient should be care- 
fully investigated ; if they are sedentary, exercise to the point of 
actual fatigue must be insisted upon, so that there is a demand on 
the reserve force of the body which will bring about metabolic 



ACUTE RHEUMATIC PHARYNGITIS. 583 

changes. This, with from one to two Turkish baths a week, is 
an important aid to the medical treatment, and is indeed almost 
curative in itself in mild cases. Careful attention should be given 
to the correction of any tendency to constipation, whether due to 
hepatic or intestinal causes. Local treatment is palliative. If 
there is excessive dryness in the throat, it will be relieved by 
allowing an effervescing tablet containing T ^- grain of pilocarpin 
to dissolve in the mouth every two hours. If, however, the secre- 
tions are excessive, a gargle of dilute hydrochloric acid, 20 drops 
to the ounce of water, or 5 to 15 grains of chlorid of soda every 
three hours in half a glass of water, will afford in many cases 
almost immediate relief. Gargling the throat with hot water also 
relieves the congestion. Quite frequently the pain and soreness in 
the muscles of the throat are sufficient to demand attention. For 
the relief of these there should be applied externally chloral 
hydrate, 1 dram to the ounce of linimentum saponis. This should 
be repeated to the point of producing slight external irritation. In 
cases in which the diathesis is more markedly lithemic, the dilute 
hydrochloric acid, in from 5- to 15-drop doses in water, after meals, 
continued from ten days to two weeks, with an interruption of a 
few days, and then repeated for two weeks longer, will aid mate- 
rially in correcting the condition. I believe that in many cases 
its continued use, aided by the prescribed exercise, will effect a 
permanent cure. Where the diathesis is rather of the rheumatic 
variety, accompanied by systemic symptoms, the salicylates are 
preferable. Salicylic acid in 3-grain doses, repeated every hour 
until the physiological effect is noted, will usually afford prompt 
relief; or it may be given in the form of the freshly prepared salicyl- 
ate of sodium, in 10-grain doses every two hours until the physio- 
logical effects are noted. Aspirin in 5 gr. doses, given every two 
or three hours, will give equally good results. The patient should 
be instructed to take a full glass of water with each capsule. 
A great disadvantage of the salicylates is a. tendency to cause 
gastric disturbance. This can be avoided in many cases if the 
salicylates are ordered after meals, and the patient is instructed 
to take from 3 to 10 drops of dilute hydrochloric acid before 
meals. If, however, the salicylates cannot be taken, bicar- 
bonate of lithium in 10-grain doses every three hours is equally 
beneficial. This may be alternated with benzoate of sodium in 5- 
to 15-grain doses every three hours. Equally beneficial results 
may be obtained by the administration of 3- to 5-grain doses of 
salophen three or four times daily. In administering the salicyl- 
ates, or indeed in the treatment in general of the gouty or uric-acid 
diathesis, the patient should be instructed to drink large quantities 
of water. This should be insisted upon, and the patient instructed 
to drink as much water at one time as possible. This will give 
better results than if a little is taken often. Vichy water is pref- 



584 DISEASES OF THE PHARYNX. 

erable. The action of the kidneys should be stimulated. There 
should be administered from 2 drams to \ ounce of Basham's mixt- 
ure every two to three hours during the acute attack, and three 
times during the day, while treatment for the correction of the 
diathesis is continued. 



CHRONIC RHEUMATIC PHARYNGITIS. 

Synonym. — Gouty sore throat. 

Definition. — This is a chronic inflammatory process in which 
there is permanent alteration in the pharyngeal mucous membrane 
brought about by the continued irritation, as manifested in the 
uric-acid diathesis. 

Etiology. — The etiology is the same as for the acute process ; 
in fact, the condition is simply a continuation and the result of 
repeated attacks of acute inflammation, and the changes in the 
tissue are very much the same as those in simple acute pharyn- 
gitis. 

Pathology. — Besides the subacute inflammatory symptoms, 
there is a permanent thickening in the connective-tissue elements 
of the submucosa, which is due to the organization of the products 
of the inflammatory process. This process is slow, owing to the 
fact that the continued irritation is only sufficient to keep up a 
mild form of hyperemia and congestion, augmented and aggra- 
vated by sudden acute exacerbations. 

Symptoms. — The symptoms of the acute exacerbations are 
those of rheumatic sore throat ; however, there is always present 
a constant sensitiveness of the throat, with a continual hacking 
and clearing of the throat on account of the accumulated secre- 
tion or the irritation produced by the chronic inflammatory proc- 
ess. The patient is easily affected by exposure to cold and damp- 
ness, or to ill-ventilated or overheated rooms or sudden changes 
of temperature. On account of the constant irritation and the 
continued inflammatory process, there is nearly always associated 
some laryngeal involvement. This is due to the same cause as 
the pharyngeal inflammation, and in the chronic variety there is 
almost always some alteration in the voice. While the hoarse- 
ness may be only slight, the voice is altered in character and 
tone. 

Diagnosis. — The condition is not likely to be confused with 
the specific inflammations or with malignant growth, as in rheu- 
matic sore throat there is rarely, if ever, any tendency to ulcera- 
tion, while in the specific inflammatory processes this is always 
the case, and in the malignant growths, before ulceration occurs, 
examination would locate the tumor. The diagnosis, then, can 
be made from the urinary examination, coupled with the history 
of repeated attacks of sore throat. 



ANGIONEUROTIC EDEMA. 585 

Prognosis. — The prognosis, as regards the relief of the gouty 
or rheumatic diathesis, is fairly good ; however, if permanent 
structural alterations have been produced in the pharyngeal mucous 
membrane, internal medication or local applications cannot restore 
such structure to its normal condition, although by the relief of 
the exciting cause the condition may be markedly benefited, and 
the individual, as far as his personal comfort is concerned, may be 
entirely relieved. 

Treatment. — The same general rules of treatment as given 
under the acute variety should be instituted, especially the Turk- 
ish baths and the drinking of large quantities of water ; however, 
the course must be prolonged and given in sufficient doses to pro- 
duce the physiological eifect of the drugs, which must necessarily 
vary with the different individuals. The beneficial effects of large 
draughts of water in the chronic variety cannot be overestimated, 
the physiological effect of such being that it flushes the kidneys 
and promotes elimination. If the alkalies are to be administered, 
possibly the most beneficial is citrate of lithium, either plain or in 
granular, effervescing form, given in 3- to 6-grain doses every two 
hours, or given in 5-grain doses from once to three times a day. If 
frequently repeated the doses should be small. This is a better plan 
than to give a large dose once daily. Succinate of soda in 5- to 10- 
grain doses, given in half a glass of water three times daily, is 
highly serviceable. Careful attention should be paid to the cloth- 
ing worn. While it is impossible to give definite and fixed rules 
to suit every case, the patient should be warmly clad. Experi- 
ence will usually have taught him what clothing is most suitable 
to his temperament. 

ANGIONEUROTIC EDEMA. 

Angioneurotic edema is a vasomotor neurosis. It is character- 
ized by small circumscribed swellings which suddenly appear 
on various portions of the surface of the body and the mucous 
membrane ; most commonly seen about the face, especially the fore- 
head, the mucous membrane of the throat, and the surface of the 
extremities. These swellings are not inflammatory, and make 
their appearance suddenly, without any apparent cause or premon- 
itory symptoms. The disease was originally called " Quincke's dis- 
ease." Strtibing was first to describe the condition when affecting 
the throat, and he applied the term angioneurotic edema of the 
throat. Most writers believe it to be closely allied to some form 
of urticaria. The disease is not bacterial in origin. It is my 
belief, from the few cases I have observed and from the literature 
on the subject, that the condition described as angioneurotic 
edema of the throat is merely a symptom of some underlying 
etiological factor and that this factor varies in different indi- 



586 DISEASES OF THE PHARYNX. 

viduals. There is no question but that, when the various ductless 
glands are involved, such as the thyroid or suprarenal glands, this 
peculiar condition is likely to occur. It would seem to me, then, 
to be merely a local manifestation of some systemic condition. 
As none of the physiological structures are immune to this disease, 
it would lead one to believe that it is not particularly limited to 
any one structure. While it is manifested in this peculiar swelling, 
at the same time either connective tissue or mucous membrane may 
be involved. It may occur on the skin of the forehead or of 
the fauces or in the gastro-intestinal tract or may produce edema 
of the glottis, may involve the bronchial mucous membrane, also 
may be a cause of cough. 

Treatment. — Under treatment, the first and primary object 
should be to determine the exact physiological condition of the 
patient, or rather what underlying pathological cause exists, and to 
direct the treatment toward the removal of this cause. The fact 
that antitoxin has been known to effect cures in these cases rather 
proves the above statement, yet antitoxin has been known to aiford 
almost instant relief in essential asthma and other allied condi- 
tions. On the other hand, it has also caused death in a few min- 
utes after its injection in asthmatic patients, showing that the 
underlying condition is not always the same in individuals. 



INFECTIOUS GRANULOMATA OF THE PHARYNX, 
NASOPHARYNX, AND TONSILS. 

TUBERCULOSIS. 

Synonyms. — Tuberculosis of the pharynx ; Consumption of 
the pharynx. 

This is in the majority of cases a process secondary to pulmo- 
nary tuberculosis, and either concomitant with or following a laryn- 
geal involvement. It is rarely a primary process, and may be 
part of a general tuberculosis. The etiological and pathological 
characteristics have already received sufficient notice without 
repetition here. Tuberculosis of the pharynx is a comparatively 
rare condition. 

Symptoms. — The early symptoms of the disease are those of 
an acute or subacute pharyngitis, and their true import, as a rule, 
is not recognized unless strong suspicion be aroused by the pres- 
ence of an active pulmonary lesion. These symptoms intensify, and 
the membrane becomes the site of local swellings caused by the 
peculiar inflammatory infiltrate, which may involve the velum 
palati, the uvula, the pillars of the fauces, the area of the pharyn- 
geal tonsil, or, in short, any portion of the pharyngeal mucosa. 
The tonsils are in somewhat rare instances implicated, either pri- 
marily or, more commonly, secondarily, and, as a rule, the ten- 



TUBERCULOSIS. 587 

dency is for the disease in the pharynx to spread with greater 
rapidity downward than upward. Various symptoms are directly 
traceable to this infiltration and thickening of the membrane. 
Thus a stiffened velum palati may prevent proper obstruction to 
the choanse, and allow the entrance of liquids or solid bits of 
food into the nasal chambers during deglutition. The same 
condition favors the accumulation and inspissation of mucus or 
mucopurulent discharge, especially after ulceration, which may 
require considerable effort to dislodge. Thickening of the uvula 
may be sufficient to produce a short, hacking, irritative cough, 
repeated painfully often, and the two combined may effect con- 
siderable change in the voice. With the swelling begins the for- 
mation of numbers of miliary tubercles as minute yellowish spots 
beneath the surface of the membrane. These last a variable length 
of time, soften, rupture, and form minute ulcers, which are small, 
perhaps hardly noticeable, have a well-defined but irregularly 
rounded outline, are shallow, the floor covered by a grayish secre- 
tion, without marked inflammatory areola, and they are attended 
by a general pallor of the membrane. Spread of the ulcerative 
process is rapid. Each focus enlarges in breadth and depth, and 
neighboring areas unite to form a more extensive spread of the 
necrotic process. The pharyngeal membrane may show ulcerative 
foci separated by intervening bits of unaffected tissue and present- 
ing the so-called " moth-eaten " appearance. It may be possible 
to observe miliary tubercles in the bases of the ulcers, possibly 
even granulations in masses along the edge, and bleeding may 
follow irritation by a probe or foreign body. The secretion 
increases, becomes more slimy and tenacious, and may interfere 
with respiration or give it a peculiar wheeze. The spread is rapid 
and extensive, and may even lead to complete destruction of the 
palatal structures, with the attendant opening of the nasal cham- 
bers to the entrance of material from the pharynx. Not infre- 
quently the ulcerative process is intensified by the existence of the 
same process in the larynx, or even in the mouth. Partial cicatri- 
zation may occur in some cases, but it is a rare sequence. Pain 
is a constant symptom, variable in degree, and its location is 
dependent upon the site of the morbid process. The dry, parched, 
burning ache of the earlier stages grows into -the sharp, lancinating 
pain of the late periods, which may radiate to the ear, or even 
cause otalgia, especially if the lateral wall of the pharynx or the 
pillars of the fauces be the seat of active processes. Pain is inten- 
sified on motion, and tenderness of the affected area is extreme. 
Deglutition becomes progressively more and more painful and 
difficult, and food is often not taken because of the agony in swal- 
lowing. The voice is thick and muffled, and the patient has 
difficulty in clearing the throat, both because of the ensuing pain 
and because of the tenacious secretion which is fairly abundant, 



588 DISEASES OF THE PHARYNX. 

but is not noticed in the greater expectoration from the lungs. 
Cough is usually referable rather to the pulmonary lesion than to 
the pharynx, though a dry, hacking, irritative cough attends the 
latter manifestation. There is marked fetor of the breath. The 
other symptoms to be noted are those traceable to the lesion of the 
lungs, which either accompany or shortly follow the process in the 
upper respiratory region. These include, of course, emaciation, 
fever, sweats, and the whole train of well-known symptoms of 
pulmonary tuberculosis. 

The diagnosis is usually not difficult, but it may be some- 
what obscure before the ulcerative action begins. Scrapings from 
the ulcer should give strong presumptive evidence on a bacte- 
riological examination. The history of the case, the tubercular 
lesions elsewhere, and the local symptoms given should be sufficient 
for recognition. The very possible existence of a mixed infection, 
especially with syphilis, is to be carefully borne in mind. 

The prognosis is very grave. Some few cases of local infec- 
tion have recovered after removal or destruction of the diseased 
area. In all these rarer instances cicatrization has occurred and 
an apparent cure resulted. Death is rarely delayed more than 
six months. 

Treatment. — Primary tuberculosis of the pharynx alone 
rarely ever occurs. It is usually subsequent to pulmonary or 
laryngeal tuberculosis. As to the treatment of the condition, the 
method is the same whether it be primary or secondary. The 
prognosis, however, is more favorable in the primary uncomplicated 
cases than in those associated with pulmonary or laryngeal lesions. 
The local treatment in any case is directed toward the alleviation 
of the intense pain and discomfort caused by the ulceration, as, 
with the exception of possibly an absolutely primary local lesion, 
a cure can hardly be hoped for. Owing to the fact that the 
patient's general vitality is much lowered, together with the 
presence of the specific infective agent, the healing of the ulcer is 
a slow and almost hopeless process. For the relief of the pain, 
which is aggravated by swallowing, the local application of a 5 to 
10 per cent, solution of cocain will suffice. This, however, is only 
palliative, and from the chronic condition of the ulcer will necessi- 
tate the long-continued use of the drug, with the necessarily bad 
effects, not only locally, but also on the general system. I have 
obtained equally good results, not only for the relief of the local 
irritation, but also from its cleansing as well as its slightly 
antiseptic action, by the use of dilute nitric acid in an equal 
quantity of water, applied directly to the ulcerated areas either by 
means of an applicator or in the spray form. A simple therapeutic 
agent which gives much relief is the juice of the pineapple used as 
a spray or gargle ; it is cleansing and acts as a slight astringent, 
also relieving the irritation and pain. 



TUBERCULOSIS. 589 

The treatment by curetment (Fig. 216), while it may be a 
beneficial method, is questionable as a curative measure, for the 



o-, 




Fig. 216.— Mayer's pharyngeal curet. 

healthy underlying structure is protected by the limiting membrane 
peculiar to the specific inflammatory processes, and this prevents 
spreading other than by continuity of tissue. Now, unless the 
curetment be thoroughly done and all of the infected area removed, 
the lymphatic system may be opened and metastasis take place. 
The most satisfactory plan of treatment is the thorough cleansing 
of the ulcer with an antiseptic alkaline solution, such as — 

1^. Sodii biboratis, 

Sodii bicarbonatis, da gr. x (0.65) ; 

Acidi carbolici, gtt. ij (0.12) ; 

Aquae, q.s. ad flgj (30.0).— M. 

The surface should then be dried and an acid applied. The 
repeated use of Mackenzie's carbolic-acid throat-tablets affords 
considerable relief when the membrane is dry. Of the various 
acids used I have obtained the best results from the use of the 
dilute nitric or hydrochloric acid. This should be repeated two 
or three times a day. The application of powders, such as iodo- 
form, orthoform, and aristol, are of doubtful value, but decidedly 
diagreeable to the patient. In the early or catarrhal stage the 
membrane should be cleansed and dried and a mild astringent 
applied, such as tannin, 8 to 10 grains to the ounce; at the same 
time there should be administered internally carbonate of guaiacol 
in 1- to 5-grain doses three times daily. The spraying of the sur- 
face with glycerated extract of suprarenal capsule is useful in these 
cases. Injection of 98 per cent, alcohol in the cases in which the 
lesion is primary to the pharyngeal structure will be productive of 
good results ; however, if it is complicated with pulmonary tuber- 
culosis, owing to the lowered vitality of the individual, local appli- 
cations or injections will be of little avail. The placing of the 
patient under the proper climatic conditions is of the greatest 
importance, and, when the diagnosis is established early, the 
patient should be at once sent to a suitable climate, and such 
constitutional remedies as cod-liver oil, hypophosphites, or the 
lactophosphate of lime should be administered. 



590 DISEASES OF THE PHARYNX. 

Lupus. 

The exact nature of this affection has for a long time engaged 
the attention of medical men, and numerous opinions as to the 
process have been advanced. It is, however, established almost 
beyond question clinically, by study of the minute anatomy and 
pathological processes and by the presence in small numbers of the 
bacillus of Koch within the lupus structures, that the disease is a 
local tubercular manifestation. The strumous diathesis is favorable 
to its origin, but its occurrence does not depend upon the existence 
of tuberculosis of special organs or a general tubercular involve- 
ment. In the pharynx it may be primary, but, as a rule, is 
secondary to a previous nasal or buccal process, which in turn may 
follow extension from the dermal structures of the nose or face. 
It may involve any part of the pharyngeal mucosa, the pillars of 
the fauces, or the tonsils. It is of slow progress and causes exten- 
sive loss of tissue. Males seem less disposed to its occurrence than 
females ; it is more common in early life, and in many instances it 
is preceded by repeated attacks of pharyngitis. 

Pathologically, there is to be observed a cellular infiltrate into 
the deeper layers of the mucous membrane and the structures 
beneath. This infiltrate is not a diffuse process, but is seen in 
masses lying between trabecular of connective tissue and glandular 
structure and placed in close relationship with a blood-vessel. 
Microscopically, these masses show the characteristics of granula- 
tion-tissue, with numerous pale, well-formed giant-cells among the 
cellular elements, and in scanty numbers the bacilli of tubercu- 
losis. The subsequent appearances are those of ulceration and 
extensive and rapid cicatrization, or more rarely of absorption of 
the inflammatory tissue. The process may be noted in any part 
of the pharynx, the pillars of the fauces or the tonsils, and is 
much slower in its progress than the other specific inflammatory 
conditions. 

The symptoms of the disease are subjectively not severe, and 
quite frequently the process has been of considerable standing 
before the patient has deemed it of sufficient severity to consult a 
physician. Pain is practically absent, and the proper performance 
of the pharyngeal functions is not altered to any extent unless 
the epiglottis is severely involved, or the region surrounding the 
Eustachian orifices becomes swollen or adherent to neighboring 
structures in such a way as to occlude the openings. Early in the 
history of the case the membrane of the affected areas becomes 
livid, smooth, and dry, and may even be granular. Small lighter- 
colored points may be observed, which mark the site of the typ- 
ical lupus swellings. Soon these appear as small miliary nodules, 
from the size of a pin-head to half a pea, plentifully scattered 
over the affected area and giving it a mammillated appearance. 



TUBERCULOSIS. 591 

In color they do not differ from the membrane itself, are smooth, 
and to the touch are soft, easily penetrated, and without pain. In 
certain cases this may be the extent of the process, and absorption 
of the inflammatory infiltrate may lead to extensive loss of tissue 
without external ulcerative phenomena. More usually, however, 
ulceration ensues. Each nodule softens, breaks down, and forms 
a necrotic focus slightly elevated above the adjacent tissue, with 
thickened and inflamed borders, and covered with a tenacious, 
glairy, grayish secretion in fairly considerable amount. These 
points of loss of tissue may slowly run together and produce by 
confluence larger areas of ulceration, or they may remain discrete 
and slowly increase in size. The adjacent membrane shows the 
nodular formation preceding its involvement in the necrotic proc- 
ess. Ulceration becomes extensive and is responsible for consid- 
erable tissue-loss. It is not, however, so deep as that observed 
in syphilitic necrosis of the tertiary type. Following ulceration, 
the characteristic tendency of the disease for cicatrization is appa- 
rent. This follows closely the ulcerative process, and both may 
not infrequently be seen coincidently. The fibrous cicatrices so 
formed are strong and firm, and by their subsequent contraction 
lead to extensive alteration in the contour of the entire pharynx. 
Thus ulceration in the lateral regions may cause destruction of the 
tissue in the neighborhood of the Eustachian outlet. Not un- 
commonly, ulcerative surfaces coming in contact especially with 
the posterior pillars and the lateral walls may lead to a firm union 
and formation of practically a single membrane, with ulceration 
marked upon its surfaces. Such conditions may cause occlusion 
of the Eustachian tube and precede deafness, or catarrhal and sup- 
purative disorders of the middle ear. The velum palati may 
undergo swelling, subsequent ulceration, and contraction, interfer- 
ing with deglutition. The posterior nares may become closed 
and give the voice a nasal twang. The tonsils may become 
inflamed and granular, and be indistinguishable from the pos- 
terior pillars. Soft, reddened ulcerations appear, which show a 
slight tendency to spread, and, finally, cicatrization with its shrink- 
age reduces the organ to a mere whitish mass of fibrous tissue, not 
differing from similar tissue in the other affected regions. The 
uvula may shrink to a mere rudiment. The epiglottis rarely 
escapes, and may be completely destroyed, or may dwindle to a 
mere fragment. The pharyngeal membrane is shrunken, traversed 
by web-like bands of cicatricial tissue, which may not infrequently 
form pockets retentive of considerable secretion and demanding a 
releasing incision. The course of the disease is not usually marked 
by any special impairment of the general health. 

The diagnosis is not difficult in the majority of cases, and 
yet the process is extremely apt to be wrongly considered as syph- 
ilitic. The history of the case, the slow process, more shallow 



592 DISEASES OF THE PHARYNX. 

ulceration, and more rapid cicatrization of lupus, together with 
failure of response to antisyphilitic treatment, should clear up any 
existing doubt. 

The prognosis is not favorable for cure of the disease. A 
few cases of early recognition have been reported cured through 
prompt and extensive tissue-ablation. More commonly it defies 
treatment. Many cases die from tubercular conditions of the 
lungs, and others from complications due to local impairment. 

Treatment. — Treatment should consist in the thorough 
removal of all the diseased tissue. This can be accomplished by 
curetting or by the galvanocautery. Chemical caustics, while of 
remedial value, are more difficult to control. The small nodular 
masses, before breaking down occurs, should be cauterized with 3 
to 5 per cent, nitrate of silver. The ulcerated areas should be 
repeatedly cleansed with acid gargles, which are in themselves 
slightly astringent and decidedly germicidal. The best is dilute 
hydrochloric acid, 10 to 20 drops to the ounce. After the thor- 
ough cleansing of the surface, where there is tendency to marked 
ulceration, good results can be obtained by the insufflation of 5 
per cent, pyoktanin in stearate of zinc. The patient should 
always be instructed to fill the lungs to their utmost capacity 
before the insufflation, so that the first respiratory effort will be 
expiratory. 

When the diseased area extends over the entire pharyngeal 
surface, involving adjacent structures, the laryngeal complications, 
not only from the spreading of the disease, but also from the threat- 
ened edema, may necessitate tracheotomy. 

SYPHILIS. 

Both the acquired and congenital forms of syphilis are to be 
noted in these regions. The acquired form may be contracted at 
any age, but it is more frequently noted after puberty. The 
hereditary form is seen in both secondary and tertiary manifesta- 
tions ; the former being the early variety, seen usually during the 
first month or so of the patient's existence ; while the latter are 
rarely seen before the fifteenth year, and constitute the type known 
as late congenital syphilis. The syphilitic condition of the throat 
constitutes a not insignificant portion of the general specific display. 
The three periods are well marked, and are attended by distinct 
and characteristic symptoms. In congenital syphilis, a diffuse 
hyperplastic condition (syphilitic hyperplasia of the pharynx) 
is sometimes observed in the mucous membrane of the pharynx 
and larynx. This is especially true about the epiglottis, the 
aryepiglottic folds, and the interarytenoid folds. This hyper- 
plasia is somewhat on the order of the specific excrescences 
or vegetations sometimes observed at the junction of the 



SYPHILIS. 593 

skin and mucous membrane. There is marked tendency to ulcer- 
ation of this structure and frequently there is considerable edema. 
The connective-tissue elements seem to be thickened or hyper- 
plastic, more on the order of a cell-infiltration than of a true phy- 
siological hyperplasia. This condition was first described by 
Semon. 

Curiously enough, this diffuse hyperplasia in the congenital 
cases yields very slowly to antisyphilitic treatment. The best 
results will be obtained by the use of the mixed treatment, or 
by alternating the iodides with mercury. When ulceration occurs 
it presents the bluish, ragged, chronic appearance as seen in lupus 
and in the dry form of tubercular ulceration. 

In the tertiary forms, especially involving the structures of the 
nose and throat, where internal administration of the iodids and 
mercury have failed, the therapeutic measure should not be aban- 
doned without resorting to the mercurial inunctions. 

The Primary Form. — Xext to the genitalia, the lips, ton- 
sillar and pharyngeal sites are, perhaps, the most frequent seats 
of the primary lesion. Exception might be taken to this order ; 
but I believe that if careful observation be made of the tonsillar 
bands it will be found to be true. Infection through infected uten- 
sils, surgical instruments, pipes, finger-nails, and kissing. Cases 
have been reported of infection from a syphilitic nurse, while dis- 
gusting sexual perversions are responsible for a considerable per- 
centage. Females seem to be more affected by the primary sore 
in this site than males. The tonsils are more frequently the seat 
of chancre than the remaining structures, probably because of their 
follicular openings being favorable to retention of the infecting 
principle and because of their close proximity to the mouth. One 
tonsil is usually affected, but cases in which the lesion has been 
bilateral have been reported. A large proportion of cases undoubt- 
edly escape notice, or are incorrectly diagnosticated through refer- 
ence of their symptoms to a catarrhal condition. The symptoms 
vary, but, as a rule, are not severe, nor of extended duration. 
There are the manifestations of a more or less severe inflammatory 
reaction in the adjacent membrane, while it may be possible to 
observe the chancre as an indolent inflammatory nodule, isolated, 
rapidly becoming deprived of its investing epithelium, and appear- 
ing as a reddish-gray denuded area, with irregular margins and 
covered by a thin, glairy secretion. The base is firm and indurated, 
and the adjacent membrane inflamed. This persists a short 
while, and then disappears spontaneously, its site being marked by 
a small yellowish cicatrix. If the pharyngeal walls be already the 
seat of an active morbid process, it may be impossible to locate or 
perhaps diagnosticate absolutely the entrance site of the specific 
poison. The lesion may occur in any abraded point of the pharyn- 
geal membrane. Chancre of the tonsils is, however, the most 
frequent form, and even this may be very much obscured bv the 

38 



594 DISEASES OF THE PHARYNX. 

inflammatory phenomena. It may, however, be possible to observe 
the typical sore upon the surface of the organ and to palpate its 
•hard base with a probe. Or the tonsil may mark the entrance of a 
specific virus by a mild form of tonsillar inflammation, or may 
take the form of a somewhat extensive ulceration of considerable 
depth and severity. Some few cases show a tendency to cover 
the chancre with a pseudomembranous investure, the removal of 
which is easy, and discovers at once the typical sore beneath. The 
entire organ is markedly inflamed, indurated, and enlarged. The 
primary sore is not of long duration and subsides spontaneously, 
leaving an indurated inflammatory mass or scar, with subsequent 
contraction. With its disappearance cessation of the local inflam- 
matory phenomena occurs. Pain during the presence of the 
chancre is a variable quantity, but there are always more or less 
dysphagia, local tenderness, and the subjective annoyances of a 
sore throat. If the lesion be placed upon the posterior pillars, 
pain referred to the ear may be noted, and aural symptoms may 
develop through occlusion of the Eustachian outlets. A pro- 
nounced and typical condition of the lymphatics attends the 
presence of the chancre, which consists in an indolent, slow swell- 
ing of the glands along the angle of the jaw and sternocleidomas- 
toid muscles of the affected side, or both sides if both tonsils are 
affected, or if the chancre is located on the median line of the 
pharynx. * The skin overlying the glands is not discolored ; the 
glands themselves are felt as firm, freely movable bodies, well 
outlined, and there is no tendency to suppuration, though the 
swellings may become quite noticeable. 

The Secondary I^esions. — These may belong to either the 
congenital form or the acquired. If congenital, they are seen 
usually within the first month or so of the patient's birth. If 
acquired, they appear with the other systemic secondary symptoms, 
usually some six to eight weeks after the primary infection has 
occurred. The chief manifestations are the erythema, the mucous 
patch and, in some cases, the superficial ulcer. The erythema is, 
as a rule, the earliest in appearance, and may cover the entire 
visible pharyngeal wall, distributed symmetrically or occurring in 
an isolated area. No portion of the pharyngeal and tonsillar sur- 
faces is exempt from its possible occurrence ; but, as a rule, it is 
rarely noted above the level of the hard palate. It may present 
the appearance of a diffuse, dusky, dirty reddening, or more com- 
monly occur in collections of small, well-defined, dusky-red areas 
that are separated by small intervening spaces of comparatively 
normal tissue, and give the throat an almost pathognomonic mot- 
tled appearance. With the erythema there are possibly some 
slight local symptoms, such as cough, a dry or tickling sensation, 
and dull pain. There may be a slight elevation of temperature ;, 
in short, the usual symptoms of a mild catarrhal pharyngitis may 
all be noted. The erythema usually remains as long as the cuta- 



SYPHILIS. 595 

neous eruptions are present, and, like the latter, is readily scat- 
tered by the exhibition of antisyphilitic treatment. Following the 
appearance of the erythema at a varying period, mucous patches 
may be observed on the membrane. These may occupy any posi- 
tion on the pharyngeal, tonsillar, or faucial surfaces, though in the 
latter sites they are more commonly observed on the anterior aspect 
than on the posterior. They begin as dark, dusky-red, rounded 
elevations, well defined upon the membrane, which undergo soften- 
ing and superficial necrosis and form rounded patches with well- 
defined borders, projecting slightly above the surface of the adjacent 
membrane, covered by a grayish and very virulent secretion, and 
surrounded by an inflamed areola. As a rule, they are not deep, 
do not spread, and end in cicatrization and contraction of the 
resultant fibrous scar. They may be attended by some fetor of 
the breath, but aside from local tenderness give rise to little or no 
subjective annoyance. Some cases show a tendency to a super- 
ficial erosion of the membrane, preceded by a whitening or cloudiness 
of the upper layers. This, however, does not go on to any serious 
extent, and needs only a brief mention. One peculiar feature of the 
secondary period is that of the tendency which its manifestations 
have to re-appear under certain circumstances, such as the cessation 
of specific medication. 

The Tertiary I^esion. — Tertiary manifestations may occur 
as early as seven years, or not be observed until twenty or more 
years after the primary infection has occurred. In the hereditary 
form it is rarely seen before the fifteenth year. The characteristic 
lesion is the gumma, to the development, ulceration, and subse- 
quent cicatrization of which are due the major portion of the pro- 
found structural changes that occur. In certain rare cases tertiary 
syphilis may show itself as a widespread, malignant, gangrenous 
ulceration of the entire pharynx, and prove rapidly fatal. The 
characteristics of gumma-formation have been too thoroughly 
described elsewhere to need repetition here. Any portion of the 
area under consideration may be the seat of their formation, and 
this in turn may be either in discrete, well-defined tumors, or take, 
less commonly, the form of a diffuse, inflammatory, gummatous 
infiltrate. The tumors formed are smooth, veil defined, and, 
before degenerative changes occur, show no noticeable discolora- 
tion of the overlying membrane. They persist a variable length 
of time, and then inevitable ulceration, both of the gummata and 
of the diffuse form, takes place. The ulceration is deep and 
extensive, no tissue is exempt from its ravages, and the destruc- 
tive results of its progress baffle any attempt at adequate descrip- 
tion. The pharyngeal mucosa may be irregularly eaten away, the 
tonsils be wholly or in part destroyed, the pillars of the fauces 
eroded, and the velum and soft palate be sloughed off or perforated. 
Occasional cases of ulceration into the deep vessels of the neck, 
with a subsequent fatal hemorrhage, have been recorded. The 



596 DISEASES OF THE PHARYNX. 

bony structures at the rear of the pharynx or the vault rarely es- 
cape. Necrosis of the intervertebral discs and of the bodies of the 
vertebra^ even to exposure of the spinal marrow, has been recorded. 
The base of the skull may be exposed, and access to the brain fol- 
low necrosis and discharge of the dead basal bone. The odor from 
such extensive ulceration is pronounced and sickening. There is 
no inconsiderable amount of necrotic tissue discharged — foul, dirty, 
purulent material, with bits of worm-eaten bone mingled with it. 
Occasionally, sequestra are formed, and palpation by the probe 
gives the pronounced grating sensation of carious bone. Follow- 
ing the destructive process in certain cases, even without the use 
of antisyphilitic treatment, healing takes place by the formation 
of thick fibrous and contracting cicatrices. Following this forma- 
tion the greatest alterations in the structure are to be observed. 
The whole pharynx is irregularly drawn and deformed, the naso- 
pharynx may be obliterated, and the velum and soft palate be 
destroyed. Adhesions between neighboring ulcerated areas are 
frequently observed, with pocket-formation, or even partial or 
complete occlusion of the pharyngeal spaces. With such extensive 
alteration in structure there is, of course, profound alteration and 
even loss of the major part of the pharyngeal function. Yet, in the 
majority of cases, the process is not attended by anything like a 
proportionate amount of suffering and pain. Some patients suffer 
less actual pain than others evince from a simple catarrhal pharyn- 
gitis, and complain of nothing save the annoyance of imperfect 
deglutition and phonation. Others may experience constant dull, 
heavy pain in the throat, with agonizing exacerbations upon 
attempting to employ the pharynx in the performance of its 
normal functions. 

The diagnosis of syphilis of the pharynx and tonsils is not 
difficult in the secondary or tertiary forms. The lesions themselves 
are so pathognomonic, the extrapharyngeal symptoms so constantly 
developed, and a clear specific history so often obtainable as to 
make error practically inexcusable. Furthermore, the usually 
quick response to antisyphilitic remedies furnishes indisputable 
confirmatory evidence. The primary lesion may be very obscure 
and incorrectly diagnosticated, or if suspicion as to its character 
be aroused, it may not be confirmed until the secondary symptoms 
appear. The indolent glandular swellings of the neck and angle 
of the jaw are to be regarded as of extreme diagnostic value, and 
their true nature may be sometimes determined by a clear history 
of suspected infection. 

The prognosis is largely that of the general condition. Few 
conditions are more virulent, and none is more certain to yield to 
proper medication. The tertiary form is the gravest, and may 
prove fatal through meningeal extension or necrosis into the vital 
structures of the neck. Grave structural changes are sure to ensue 
before the influence of medication is observed, and these become 



GLANDERS. 597 

of greater extent and severity the longer that specific treatment 
is delayed. 

The" treatment of syphilis is fully given on pages 152, 701. 

GLANDERS. 

Synonyms. — Equinia ; Malleus humidus. 

Etiology. — The specific cause of the disease is a bacillus 
known as the Bacillus mallei. Morphologically, it is shorter and 
thicker than the bacillus of tuberculosis, and is found abundantly 
in the purulent discharge from the aifected sites. Primarily, 
glanders is a disease of the higher animals, especially of horses, 
which is readily communicable from them to man, and may also 
be contracted by one human being from another. The transmis- 
sion of the infection may occur in several ways. Thus, the infected 
nasal secretion may be thrown in fine spray from the nostrils of an 
infected animal by its sneezing or coughing, and thus reach the 
site of inoculation. It may be conveyed by the careless use of 
vessels used in watering them, the use of utensils or fingers that 
are infected by the virulent discharge, or by the indiscriminate 
use of clothes that have been used around the diseased animals. 
In the human race the disease is perhaps observed more often 
within the nasal limits than in the tonsillar or pharyngeal areas, 
and in these sites is not infrequently an extension from the nose- 
confines. The involvement of the mucous membrane may be 
either primary or a feature in the pyemic extension of glanders or 
farcy of the subcutaneous structures of the body. Infection 
undoubtedly requires an abrasion or some solution of continuity 
permitting free entrance of the germ to the tissues beneath the sur- 
face, though the question of possible infection through an un- 
broken surface is raised by some observers. As may be readily 
inferred, males and those employed around animals are from the 
nature of their work more liable to its contraction than others. 
The incubation-period is usually from three to five days, though 
so long an interval as three weeks may elapse before known 
exposure to infection is followed by establishment of the morbid 
process. 

Pathology. — Histologically, the phenomena of a low-grade 
inflammation are to be observed, resulting in the formation of 
masses of granulation-tissue, among the cellular components of 
which are to be observed the peculiar bacilli in large numbers. 
This soon gives way to the picture of a rapidly spreading suppura- 
tion, with extensive adjacent inflammatory phenomena. Infection 
spreads rapidly, following the line of the lymphatics, the glands 
in their course becoming swollen with inflammatory products and 
rapidly breaking down, and the general evidences of pyemia 
appearing. Necrosis of the bones and cartilages related to the 



598 DISEASES OF THE PHARYNX. 

suppurative process is not unknown, and the abscesses of the sub- 
cutaneous regions, as a rule, tend to burrow deeply. The chronic 
form differs only in that the local phenomena do not develop so 
rapidly, pus is less apt to be present, and the pyemic spread is 
not so severe or rapid as in the acute form. 

Symptoms. — Two distinct types of the affection are noted, 
based upon the rapidity with which the disease progresses, and 
termed respectively the acute and chronic forms. The acute form 
may be an extension of the process already established within the 
nasal limits, and, as such, its peculiar symptoms form a grave fac- 
tor in the original prognosis, or it may be of primary location 
within the pharyngeal areas. Inoculation by the virus is followed 
shortly by a vague, ill-defined, but persistent sense of general dis- 
comfort. In a few days pain becomes localized in the infected 
neighborhood, and the site of inoculation shows a small, reddened, 
and somewhat tender nodular swelling. The nodules increase in 
number, and vary in size from a millet-seed to a small cherry. 
Degenerative changes ensue, the swellings soften and break down 
and form ill-conditioned ulcers, with thin, undermined edges and 
with a moderately deep floor covered by a yellowish, purulent 
discharge of a fairly thick consistency. The surrounding tissue is 
swollen and infiltrated, the ulcerative process spreads rapidly, 
and the adjacent areas coalesce in an extensive phagedenic proc- 
ess. Pain is generally constant, its location and severity modified 
by the site of the morbid process. It may be a dull, continu- 
ous or intermittent distress, or sharp, lancinating pain referred not 
alone locally, but to the general distribution of the fifth pair of 
nerves. Deglutition and phonation become impaired and painful 
to a degree proportionate to that of the morbid involvement within 
the pharynx. Lymphatic involvement is early and rapid. The 
cervical glands enlarge, soften, and may break down into deeply 
burrowing abscesses. The sublingual and submaxillary glands 
swell and suppurate, and lead to the formation of freely discharg- 
ing external fistulas. The discharge from the affected areas is 
fairly profuse, and, microscopically, shows the presence of the 
peculiar bacilli in abundant numbers. In many cases this in- 
fection of the subcutaneous structures precedes or accompanies 
the lesions in the throat. The lymphatic structures become 
deeply involved ; the glands swell, forming the so-called " farcy 
buds/ 7 soften and break down, and eventuate into deeply bur- 
rowing abscesses. The joints are attacked, and suppurative 
arthritis ensues. Metastatic abscesses form, and the general symp- 
toms of a severe pyemia follow. Constitutional symptoms are 
severe and exhausting, appear early in the establishment of the 
disease, and increase in intensity as it progresses. Markedly 
irregular fever is present. Headache, chills and rigors, profuse 
sweats and varied circulatory disturbances attest the septic proc- 



GLANDERS. 599 

ess. Exhaustion is rapid, emaciation profound, and colliquative 
diarrhea and drenching sweats, often with wild delirium, mark the 
end of the patient's wretched existence. The symptoms of the 
chronic form are more obscure, constitutional impression is less 
profound and rapid, and the skin-lesions are not so generally 
attendant. Often it is regarded by the patient as a chronic catarrh, 
and he seeks relief for the condition, the true nature of which 
may not be suspected, or not infrequently wrongly diagnosticated, by 
the consulting practitioner. The usual subjective symptoms of a 
subacute pharyngitis are complained of. Pain is variable, at times 
absent, possibly at other times excruciating. Lymphatic involve- 
ment of the cervical glands is slow or, apparently in some cases, 
absent. The entire train of subjective symptoms may exist for 
awhile and then leave, to appear at variable later periods, with 
usually increasing severity. The constitutional symptoms are less 
marked in the earlier stages of the disease and may grow gradually 
worse, or reserve their severe exhibition for the closing scenes of 
the patient's life. Examination of the affected regions shows the 
presence of smooth, reddened elevations of well-defined but irreg- 
ular contour. At varying points on the surface of these a thin, 
yellowish discharge may be seen coming from ulcerated areas, the 
edges of which are smooth, rounded, thin, and overhanging. Not 
infrequently small bridges of tissue may be seen crossing them. 
These swellings are friable, and are easily penetrated by a probe 
with slight pressure, and on its withdrawal considerable bloody 
discharge oozes from the point of puncture. Tenderness is not 
marked, nor, as a rule, are the functions of the throat painfully 
deranged. Swallowing and speaking become, however, progress- 
ively impaired, with steadily increasing size of the morbid swell- 
ings, which may so enlarge as to threaten mechanical stoppage of 
the pharynx. Death occurs from the gradual exhaustion or in an 
acute exacerbation of the disease. 

Diagnosis. — Absolute diagnosis rests upon the obtainable 
history of infection, upon the finding of the bacilli, and upon the 
inoculation of a guinea-pig with the infected discharge. The acute 
form, when typically developed and attended by the cutaneous 
display, presents a picture that should at least raise a suspicion as to 
the character of the malady. Variola has been mistakenly diagnosed, 
and the two conditions may readily be confused. The chronic 
form is less recognizable by its symptoms, and not uncommonly is 
mistaken for a malignant neoplasm, especially sarcoma. Thus, in 
a case seen in consultation by the author the condition had been 
existent for some six months, portions of the affected tissue had 
been examined microscopically, and an absolute diagnosis of small 
round-celled sarcoma had been given. The presence of the pecul- 
iar germ in the discharge led to the suspicion of glanders, which 
subsequent inoculation of a guinea-pig proved correct. This pro- 



600 DISEASES OF THE PHARYNX. 

cedure gives the absolute diagnostic data. Perhaps no better 
place than this could be chosen to urge upon the practitioner the 
need to keep in mind the infectious gramilomata in forming a diag- 
nosis of obscure throat-troubles. 

Prognosis. — The acute form is invariably and rapidly fatal. 
Some few cases of the chronic type have been reported as recov- 
ering, but the majority live less than two years after the disease 
is established. 

Treatment. — The treatment should consist in the curetting 
and cauterization of the ulcers, and the radical and thorough 
removal of any suspicious growths. Antiseptic washes, such as 
carbolic acid, 1 : 60, or dilute hydrochloric acid, 5 to 20 drops 
to the ounce of water, are highly beneficial. Constitutional treat- 
ment should consist in the administration of tonics, such as iron 
and strychnin, in heroic doses. Iodid of potassium, pushed to its 
full physiological effect, has some influence on the disease. When 
a positive bacteriological examination has been made, though the 
curative effect of mallein is still doubtful, it should be employed. 

ACTINOMYCOSIS. 

Etiology. — The specific factor in this relation is an organism 
which, from its peculiar form as found in the discharge from the 
diseased area, is termed the ray-fungus. The exact place which 
this occupies in classification is as yet not absolutely determined. 
The organism is peculiar in that the typical ray form, which gives 
the fungus its name, is found only in the small yellowish masses 
mingled in the purulent discharge ; while within the diseased 
tissue the fungus appears as small masses of irregularly sized cells, 
and when grown externally on artificial media takes yet another 
form — that of threads in tangled masses. All of these forms are 
virulent and have produced the disease in lower animals by inocu- 
lation. Like glanders, the disease is primarily one belonging to 
the higher animals, especially the bovines, but readily communi- 
cable to man. In animals it most commonly takes the form, known 
as " lumpy jaw," and the infection is usually attributed to the 
ingestion of infected barley or rye. The fungus has not been 
identified upon the grain. Transmission to man follows any means 
whereby the fungus is placed within the structures just below the 
surface, and inoculation in this way may occur in any portion of 
the human body, or be transferred by the lymphatic or blood- 
channels. Actinomycosis of the pharynx and tonsils is a rare 
condition, but in this site may either be primary or appear as a 
secondary feature of its existence elsewhere. 

Pathology. — The implantation of the fungus leads to the 
development of a granulation-tumor, which in its general features 
is not unlike the local inflammatory process of tuberculosis. This 



ACTINOMYCOSIS. 601 

is the nodule of small round cells, containing giant and epithelioid 
cells, and among the cellular constituents the fungus itself may 
sometimes, though not always, be marked more rapidly, perhaps, by 
the use of certain differentiating stains. This is followed shortly 
by an inflammatory reaction of considerable moment, in the 
adjacent tissue, resulting in the proliferation of all the tissue- 
elements and the formation of morbid tissue that is easily to be 
mistaken for sarcomatous growth. A chronic and intractable sup- 
puration ensues with the formation of ill-conditioned sinuses, 
though whether the ray-fungus is itself pyogenic or suppuration 
follows from mixed infection is a question not yet decided. Infec- 
tion may be transferred both by the lymphatics and blood-vessels, 
and it is apparently spread more frequently by the latter means. 
The disease is essentially chronic in its nature. 

Symptoms. — These may be summed up into two classes — 
those referable to the local tumefaction and purulent discharge, 
and those referable to the general intoxication of the system by 
the suppurative products or its metastatic spread, and which do 
not differ from those of a chronic suppuration. The local symp- 
toms are of slow development, and are largely those of gradual 
mechanical interference with pharyngeal function. At the site or 
sites of inoculation a small rounded and reddish elevation ap- 
pears, attended by the usual subjective annoyances of an attendant 
pharyngitis. The adjacent tissue becomes sw T ollen and tumefied, 
and the evidences of an acute surrounding inflammation soon 
change to the more permanent engorgement and solidity of a chronic 
condition. The swelling is irregular, but well outlined, firm to 
probe-palpation, and not oversensitive, and increases in size but 
slowdy. There follow suppuration and the formation of angry- 
looking sinuses, from which issues more or less of a purulent dis- 
charge, in which are the small yellowish pellets or masses com- 
posed largely of the typical ray-fungi. The discharge is persistent, 
and the sinuses extend deeply and involve extensive tissue-destruc- 
tion. Spread of the condition does not, as a rule, occur, and it 
sIioavs a tendency, if it occurs elsewhere, to do so as an isolated 
swelling, rather than a connected overgrowth from the original 
focus. Pain is a variable quantity, and depends largely upon the 
seat and extent of the peculiar swelling. Usually there is more or 
less of a continuous, heavy aching felt locally, and this may at 
times be eased or intensify into acute distress. Fetor of the breath 
and gastric disturbances from the purulent discharge are liable to 
be attendant symptoms. The appearance of the disease elsewhere 
by metastasis is to be expected, especially its development in the 
lungs or the alimentary tract, though no portion of the body is 
free from possible invasion. The systemic symptoms may be 
severe or slight, according to the degree of involvement and the 
exit of suppuration-products, and do not differ in their character 



602 DISEASES OF THE PHARYNX. 

from those usually observed in any chronic suppurative condition. 
Death occurs from slow exhaustion or through some intercurrent 
affection or complication. 

Diagnosis. — This is usually impossible when attempted upon 
the symptoms alone. Diagnoses of sarcoma are usually made, 
backed up by wrongly adjudged sections of the diseased tissue in 
question. Absolute diagnosis is impossible, except upon the 
identification of the ray-fungus in the purulent discharge and its 
confirmation by animal inoculation. 

Prognosis. — The disease is of an essentially chronic nature, 
and may run months before the death of the patient. Prompt and 
very early and thorough extirpation of the infected area offers 
a good chance of release from its clutches. Unfortunately, it is 
too often not seen or recognized until beyond other than palliative 
treatment. 

Treatment. — Medical treatment is usually of no avail, 
although some few cases have been cured by the administration 
of iodid of potassium in enormous doses. Nitrate of silver 
administered internally, beginning with minute doses and pushing 
it up until the full physiological effect of the drug is obtained, 
will exert some beneficial influence. The patient's general health 
should be sustained by the administration of tonics. Experi- 
mentation with toxins, such as injection of tuberculin, has not 
proved satisfactory. Unless vital structures are involved, the 
prompt and complete extirpation of all the diseased tissue is 
the safest plan of procedure. 

RETROPHARYNGEAL ABSCESS. 

This is a collection of pus, which may be found either well up 
behind the velum palati, or by burrowing may involve the medi- 
astinal or cervical structures. If occurring in infancy or early 
childhood, the lymphatics are usually at fault, and the condition 
differs in its entirety from that occurring in adult life, when the 
pus is found in the cellular structures. Therefore, in considering 
this pharyngeal disease, we shall divide it, first, into abscess occur- 
ring during infancy, and, second, into abscess occurring during 
adult life. In the offspring of tuberculous or syphilitic parents 
the collection of pus is often found in the early years of life ; the 
cause of the condition is not well understood, except that it is an 
infection of the glandular structures attendant, in most instances, 
upon an inherited tuberculous or syphilitic diathesis. It is most 
likely secondary to infection of the lymphatic glands. 

In children the abscess is usually confined to one side, and is 
not usually found in the center of the pharynx. The lax arrange- 
ment of the pharyngeal mucosa favors the collection of pus, and 
allows easy burrowing in almost any direction. Commencing, 



RETROPHARYNGEAL ABSCESS. 603 

as a rule, insidiously in children, attention may not be called to 
the collection of pus until symptoms of pronounced dyspnea or 
attacks of choking on attempting to take food are noticed, the 
condition resembling more the chronic abscess and having only 
slight clinical phenomena of inflammation. In other cases the 
very symptoms of the disease may be such as to call attention at 
once to the pharynx, dependent, of course, on the position of the 
abscess. There may be a slight cough, followed by a peculiar 
alteration of the voice, which Peigenier describes as " cri de 
canard" 

In adults the onset of the condition is usually marked by 
symptoms which call attention at once to the morbid condition of 
the pharynx. This may be due to the fact that the cellular tissue 
is the structure involved. The first symptom will likely be pain, 
referable to the faucial region, increased by swallowing. The pain 
is usually out of proportion to the extent of involvement. There 
may be some slight fever at first, which may develop into a hec- 
tic type ; the symptoms, however, as in abscess dining child-life, 
depend in great measure upon the location of the lesion, whether 
it be high up in the pharyngeal wall or low down in the laryngo- 
pharynx, when difficulty on deglutition and regurgitation of food 
may be added symptoms. Pain, deep-seated and constant, increas- 
ing with the pus-formation until the abscess ruptures,, is also noted. 
Difficulty in breathing is not generally present. In some cases, 
especially if there is an associated tubercular diathesis, the retro- 
pharyngeal abscess is associated with caries of the cervical ver- 
tebrae. Such cases are extremely serious, and generally fatal. 

Diagnosis.— On inspection there will be seen an asymmetry 
of the pharyngeal structure by the bulging of one side or the 
other, which presents a bright-red, somewhat glazed appearance. 
Palpation may confirm the presence of fluid by fluctuation, and 
probe-palpation will cause it to present a marked bleaching of the 
tissues and a slowness of return to the normal red of the surround- 
ing area. In children it is to be noted that there may be little 
evidence of inflammation about the abscess, so that the diagnosis 
depends entirely upon the recognition of the tumor encroaching 
upon the lumen of the pharynx. Retropharyngeal abscess in a 
child may be mistaken for croup, bronchitis, or edema of the glottis, 
and care should be taken to differentiate the condition from the 
possibility of an aneurysm occurring in this location in adult life. 

Prognosis. — If the abscess occurs as an acute process, it 
usually runs its course in from five to ten days, discharging spon- 
taneously unless previously opened by the surgeon. ~No especial 
danger to life is threatened, except the possibility of the discharge 
of the abscess into the larynx during sleep, with consequent bron- 
chopneumonia or asphyxiation. Although the presence of this 
lesion in children is an indication of the strumous habit, the prog- 



6(M DISEASES OF THE PHARYNX. 

nosis is not rendered particularly grave, because the majority of 
these cases do not succumb, provided the character of the disease is 
early recognized. That is to say, the condition itself does not cause 
a fatal ending, but may lead to other complications, such as erosion 
of arteries and spasm or edema of the glottis, which may be the 
complication that may terminate in death. In fact, pulmonary 
troubles, frequenjtly brought on by the interference with respira- 
tion caused by the abscess, render the outlook more severe in 
children of a strumous diathesis. Abscess, as a result or symp- 
tom of disease of the vertebrae, develops insidiously, extends solely 
by burrowing, and may exist for months, recovery depending to a 
great extent on the course that the abscess has taken, although, as 
a rule, the outlook is usually fatal, as the local condition is merely 
an exhibition of the systemic infection. The inflammatory tissue 
after healing may appear as a nodular mass in the pharyngeal wall, 
and, later, give rise to permanent pharyngeal irritation. 

Treatment. — The indications for treatment vary according 
to the cause of the condition, and in the majority of cases consist 
in a prompt evacuation of the abscess-cavity. Even before the 
accumulation of pus, scarification or multiple puncture with free 
depletion of the parts should be resorted to ; this should be made 
at the most dependent portion of the inflammatory area. If pus 
has already formed, free incision should be made, and the patient 
immediately placed so that the head will be lowered, in order to 
prevent the emptying of the infectious material in the air-passages. 
Usually this can be done without the giving of an anesthetic. 
Should the lymphatic glands be involved to the extent of abscess- 
formation, the incision should be made from without, along the 
anterior border of the sternocleidomastoid muscle, pushing aside 
the blood-vessels of the neck and continuing until the pus-cavity 
is reached and opened. This necessitates the giving of an anes- 
thetic. The general condition of the patient should be improved 
by the administration of tonics, in the form of lactophosphate of 
lime, hypophosphites, iodid of iron, or double sulphid of arsenic ; 
the last-mentioned should be given in -^- to y^-grain doses. There 
should be applied to any enlarged, non-suppurating gland an oint- 
ment of ichthyol and lanolin, in equal parts. In caries of the 
spine it should be borne in mind that the mere opening of the 
abscess is but part of the procedure, and the real cause of the 
disease is not reached until the necrosed bone be removed. 

URTICARIA. 

Ecthyma, pemphigus, erythema multiforme and exudativum 
have been reported as occurring in the pharynx, and are mentioned 
in order that when found they may be taken into consideration in 
differentiating from other conditions. 



HERPES. 605 

An interesting case of pemphigus was reported by Jonathan 
Wright, in which the lesion appeared on the soft palate and the 
pharyngeal, tonsillar, and buccal surfaces. 

Urticaria may produce such alarming conditions as edema of 
the glottis, although such occurrences are very rare and are 
usually attended by some allied condition. 

HERPES. 

Synonyms. — Pharyngitis herpetica ; Common membranous 
sore throat ; Aphthous sore throat ; Benign croupous angina ; 
Simple membranous sore throat. 

Definition. — This disease consists in the occurrence of a num- 
ber of small discrete points of eruption scattered over the fauces 
and pharynx, which, after lasting from a few days to a few weeks, 
disappear only to recur. The condition may continue indefinitely. 

Etiology. — The condition is probably due to inflammation 
involving the terminal filaments of the nerve-fibers, giving rise to 
the characteristic eruption. While this may be true, the exciting 
causes may exist in a number of conditions — gastric and intestinal 
disorders, constitutional diatheses, especially where, from lack of 
exercise in organic structure, elimination is interfered with. It is 
also discovered as accompanying or preceding many febrile condi- 
tions, and in occasional cases is noticed as occurring at the men- 
strual period or attributed to uterine disturbances. It has been 
claimed that its neuropathic origin is well established, and attrib- 
uted to involvement of the trifacial nerve. 

Symptoms. — The attack usually comes on suddenly, with 
perhaps a slight evidence of fever, with discomfort or pain in the 
throat. There may be, however, a persistent feeling of general 
illness and gastric disturbances before the eruption appears or 
attention is called to the pharyngeal affection. It may be unilateral 
or involve both sides of the faucial cavity. The first sensation in 
the throat may be one of dryness, followed by severe or smarting 
pain radiating toward the ears, and occasionally to the nasal cavi- 
ties or the larynx. As a rule, there may be some herpetic erup- 
tion of the lips. There is usually some difficulty in swallowing, 
due to the pain, varying with the location of the diseased patches. 
Inspection shows, scattered over the soft palate, the half-arches, 
the uvula or the pharynx, discrete round or oval patches, usually 
about 6 to 8 millimeters in diameter. These are usually vesicular 
in type, arranged in groups or irregularly scattered over the struct- 
ure. They soon become excoriated, covered by a thin, yellow- 
white, false membrane, which may be readily removed, and micro- 
scopically consists of a fibrinous network, in the meshes of which 
are embedded white and a few red blood-corpuscles and degener- 
ated epithelium. Beneath this is found an irritated membrane, 



606 DISEASES OF THE PHAEYNX. 

which bleeds easily. However, the mucous membrane beneath 
may show slight, if any, alteration. There may be coincident 
involvement of any mucocutaneous juncture, or the membrane 
may form in any position of the mucous tract. If left to them- 
selves, the lesions usually last from four days to two weeks and 
spontaneously disappear, only to suddenly recur. 

Diagnosis. — The diagnosis is usually not a matter of any 
difficulty, as the mildness of the symptoms, the appearance of 
herpes on the lips, the superficial character of the membrane, and 
the freedom from consequent paralysis generally render it easy to 
differentiate from diphtheria, which is the only condition likely to 
be mistaken for herpes. It is to be borne in mind, however, that 
paralysis may occasionally follow, and may lead to a doubt as 
to the accuracy of diagnosis ; but even this may be due to the 
implantation of diphtheria upon the pre-existing herpetic involve- 
ment. 

Prognosis. — It usually terminates in recovery in from eight 
to sixteen days, with, however, a tendency to recurrence. The 
condition predisposes to infectious processes. 

Treatment. — The treatment should consist in the adminis- 
tration of sulphate of magnesium or citrate of magnesium to the 
extent of free purgation, with the continued use of succinate of 
soda in 10-grain doses, after meals. Remedial agents for the pro- 
motion of elimination should be administered. Locally, sedative 
gargles will offer some temporary relief, such as — 

fy. Chloral hydrate. gr. x (0.6) ; 

Glvcerini, 3J (4.) ; 

Aqua?, q. s. ad fl^j (30.).— M. 

Dilute the above with an equal amount of water. 
A tablet of slippery elm, allowed to slowly dissolve in the 
mouth, will afford some relief from the dryness present. 

PHARYNQOMYCOSIS. 

The growth of the spores of the Leptothrix in the follicles of 
the pharynx, tonsils, etc., gives rise to the condition known as 
mycosis. A condition which clinically resembles pharyngomycosis, 
but which pathologically is entirely different, is that of keratosis, 
and is considered under a separate heading. 

Etiology. — The etiological factor is the Leptothrix, which, 
existing in the secretions of the mouth, finds in an acid condition 
and an acute inflammation of the mucous membrane of the pharynx 
or the crypts of the tonsils a suitable nidus for growth. It is 
usually attended by some constitutional dyscrasia or local inflam- 
matory condition, either acute or chronic. There seems to be no 



PHAR YNG OMYCOSIS. 607 

doubt that there is a condition in the pharynx, occurring in the 
very young and aged, attended with the presence of the leptothrix 
— a true mycosis ; there is also no doubt that there is a condition 
occurring in middle adult life which is not dependent upon the 
presence of the leptothrix — a true keratosis. 

The spores are nearly always present in the mouth, yet the 
healthy membrane resists their action, and it is only when inflam- 
matory or diseased conditions of the gums or adjacent structures 
exist that they find a condition suitable for their growth. The 
disease is by no means uncommon. 

Pathology. — The Leptothrix belongs to the schizomycetes 
group of fungi, and is found in almost any locality in which decay- 
ing vegetable matter is present. Under the microscope they appear 
as rod-like cells embedded in amorphous granules. Various forms 
of bacteria are noted, reacting differently to the various stains, 
some staining with anilin, while others react better to the iodin 
stain, yet the difference in the action of the germ is slight, if any. 
The alteration in the membrane affected is usually superficial, and 
consists in a thickening of the superficial epithelial layer of cells, 
which have lost their usual shape and are pressed out of position. 
The epithelial cells undergo coagulation-necrosis with desquama- 
tion. The crypts are enlarged and filled with the fungoid growth. 
Occasionally, the submucosa and connective tissue are involved. 
The patches are white in color, with furred surface resembling 
mould. 

Symptoms. — The symptoms originate rather from the mechan- 
ical irritation produced by this growth than any inflammatory 
condition produced by it. Stiffness of the parts, especially on 
swallowing, with slight cough, is noticed when the growth has 
attained any size. From the local process, no disturbance of the 
general health is noticed. 

Diagnosis. — Usually arising from the lingual or faucial tonsil, 
the plant may extend to the pharynx by way of its lateral walls. 
The nasopharynx, soft palate, uvula, and tongue may be involved. 
From the cheesy masses occurring in the tonsil it may be differen- 
tiated by the fact that the Leptothrix, when torn away, leaves a 
bleeding surface, while the concretions can be easily pressed out 
without damage to the membrane. 

Clinically, the white masses resemble very closely keratosis. 
However, the masses in keratosis are much more firm, are dis- 
tinctly harder, and much more difficult to remove, although in 
either case there is some bleeding after removal. Microscopical 
examination of one of the masses will establish the diagnosis. 
Heryng found that the majority of the excrescences projected 
from a flake-like pavement-epithelium. The masses were of a 
yellowish color and finely granular in character, more or less 
transparent. He differentiates between two kinds of grafts or 



608 DISEASES OF THE PHARYNX. 

projections. The superficial or first kind are cup-like and are 
adherent to the mucous membrane and stand out in strata-like 
horny epitheleum. In the middle the mass was compact, and on 
the sides radiating filamentous projections. 

Prognosis. — The condition is harmless, but will persist indefi- 
nitely unless removed. 

Treatment. — The areas should be thoroughly curetted, fol- 
lowed by the application of 20 per cent, chromic acid or pure tinct- 
ure of iodin. The iodin should be applied twice daily. The 
mouth should be kept thoroughly cleansed by a strong boric-acid 
wash. If the condition resists this treatment, the galvanocautery 
should be energetically applied. Extensive involvement of the 
tonsils may make their removal imperative. Any existing diges- 
tive or intestinal disturbance should be corrected. According to 
the reports of some writers excellent results have been obtained 
in the treatment of this mycotic condition by the use of the #-ray. 

KERATOSIS. 

Synonym. — Hyperkeratosis. 

Definition. — This disease is characterized by the formation 
of horn-like white tufts, occurring most frequently in and about 
the tonsils, the lateral walls of the pharynx, the base of the 
tongue, and occasionally on the pharyngeal vault. The disease is 
not a new one, but until attention was called to its etiology and 
pathology by Siebenmann it was considered the same as pharyngo- 
mycosis. Since that time a number of papers have been written 
on the subject which confirm Siebenmann's view. Brown-Kelly, 
Friedland, Richardson, Goodale, and the author have studied a 
series of cases which confirm Siebenmann's view. While many 
cases have been reported lately, it does not follow that the disease 
is more prevalent, but that by careful observation and thorough- 
ness in differentiation the disease is more frequently recognized. 

The general systemic condition is not an important factor, as 
reported cases show robust health as well as asthenic conditions. 
The disease does not seem to be associated with syphilis or tuber- 
culosis. In the case reported by Gray, of Glasgow, he described 
the larynx as appearing exactly like that of tuberculosis without 
any of the clinical symptoms. In Gray's case there seemed to be 
no other lesion than that of the larynx, which is rather unusual. 

The common site is on the tonsil or the adjoining pharyngeal 
wall, though it is rarely limited to the pharyngeal surface. 

Etiology. — The disease seems to be limited more to adult 
life, most cases reported having occurred between the ages of 
twelve and thirty-five. There may or may not be some constitu- 
tional disorder. Some writers maintain that it occurs more fre- 
quently in the female; in my own observations I find the cases 
about evenly divided. The disease is not limited to the poorer 




Fig. 217.— Keratosis of tonsils and pharynx. 



KERATOSIS. 609 

classes of individuals, but seems to occur in all walks of life. 
Climatic conditions do not seem to have any etiological influence. 
In the majority of cases in which I have observed the disease 
there has been associated a certain amount of inflammatory condi- 
tion of the nasal or nasopharyngeal mucous membrane. Occupa- 
tion and hygienic . surroundings do not seem to influence the con- 
dition. 

As the leptothrix is frequently found in the mouth, it may be 
found associated with the cases of keratosis — not, however, as an 
etiological factor nor in any way associated with the process. 

Another fact in favor of the condition not being dependent 
upon the presence of the leptothrix, and that it is a true keratosis, 
is the apparent subepithelial origin of the keratoid masses. Thus, 
Siebenmann describes the subepithelial buds (connective-tissue 
papilla?) which are observed beneath the basement-membrane, 
which no doubt, by their growth, push out toward the surface and 
develop the tufts. I have found in my own studies that the con- 
dition is a subepithelial one, in that a peculiar fibrous-like band, ex- 
tending from the subepithelial structures, penetrates and obliterates 
the basement-membrane and extends out over the epithelial surface 
(see Plate II, Fig. 6). This fibrous-like exudation, which forms on 
the surface, maintains its connection with the subepithelial struct- 
ures, from which it obtains its nutritive supply. 

Some writers recognize the acute and chronic forms, and while 
it is altogether probable, I think possibly the various forms de- 
scribed are only different stages of the same pathological alteration. 

Pathology. — From the sections examined it looks as though 
whatever the pathological change may be, that it begins from 
below and extends upward. The keratosis of the epithelial 
structure, whether it be due to some bacterial irritation as the 
causal factor or whether it be associated with some subepithelial 
change, at least is dependent upon the subepithelial structure, and 
the degenerative process which takes place, as shown in the section 
(Plate I, Fig. 3) directly beneath the thickened areas on the epithelial 
surface, seems to affect these nodules, which, I think, furnishes fairly 
reasonable grounds for the deduction that the epithelial alteration 
is dependent upon the subepithelial change. It seems to be some- 
what like the specific inflammatory processes where there is cell 
proliferation, but where nutrition fails and it does not go on to 
complete organization, and in this case goes on to cornification. 
Some portions of the sections show the thickened blood-vessel 
with proliferation of the endothelial lining of the vessel walls. 
The symptom usually described in this disease, a feeling of stiff- 
ness in the throat (I believe owing to the fact that the separate 
nodules are anchored, as it were, to the definite spot, interfering 
with the elasticity of the membrane), also proves these subepithe- 
lial connective-tissue changes. 

39 



610 DISEASES OF THE PHARYNX. 

The peculiar fibrous bands (Plate II, Fig. 6) show a rather unusual 
formation, extending as they do from the subepithelial structure, 
penetrating and obliterating the basement-membrane, and extending 
out directly to the epithelial surface, are most likely organized 
connective-tissue papillae which have pushed up through the 
epithelial layer and cornified on the surface, as they continue along 
the entire surface of the section and look like organized fibrinous 
exudate. The subepithelial lymphoid structure shows slightly 
water-soaked cells, such as would be found where there is a very 
mild edema. That there is very little inflammatory process is 
shown by the polymorphonuclear leucocytes. Many large poly- 
morphous lymphoid cells show chromatin scattered throughout the 
cells. The tissue also shows many inclusion cells and the cell is 
filled with chromatin. The subepithelial cells which seem to bud 
or shoot up through the connective tissue show peculiar nuclear 
change. Siebenmann describes non-nuclear cells, while I find 
none resembling the cells described by him except those which are 
undergoing hyaline change. Those prolongations from below — 
namely, the papillary budding from the connective-tissue structure — 
are seen in normal histological sections of mucous membrane ex- 
tending only to the basement-membrane of the pharynx and upper 
respiratory and alimentary tracts. 

In fact, nearly all the sections in a general way agree with 
his description of the tissue, pigment granules being present, and 
keratohyaline disseminating throughout the structure. While 
keratoh valine is normally present in the section of mucous mem- 
brane, it is in a very limited amount and is not so easily demon- 
strated. Heryng called attention to the fact that the submucous 
masses resembled very much the pulp of a hair. This is well 
illustrated in Plate II, Fig. 7, and is due to the fact, I think, that 
the papillary layer which has shoved up through the mucous mem- 
brane at that point has undergone cornification with some hyaline 
change. The change in the epithelial cells, of course, depends 
somewhat on the variety of epithelium. The pavement-epithelium 
hardens much more readily than the cylindrical epithelium. The 
posterior wall of the pharynx contains more pavement-epithelium 
than the lateral walls or tonsillar surface. 

Biesiadeki, of Krakow, believed that on account of the iodin 
reaction of the removed portion amyloid degeneration of the 
mucous glands occurred. Stoerk found calcareous deposits. In- 
filtrations, however, are likely to occur associated with degenera- 
tion, and it is not unlikely that in Stoerk's case this had taken 
place and the concretion was a secondary formation and not a 
causal factor. Rokitansky classified the disease among the athero- 
mata similar to the change occurring in the skin ; in fact, a 
hardening or keratosis. 

Clarkson in his normal histology says the superficial epithelial 
cells are for the most part non-nucleated periplasts enclosing a 



Plate i. 







Fig. 1 shows connective-tissue loops penetrating basement-membrane. 
a is fairly normal. It shows slisht keratinization on the surface. 



The submu- 



Fig. 2 shows projecting connective-tissue papilla? in which keratinized cells show on 
the surface ; the central area is degenerated and the genetic layer of the basement-mem- 
brane is necrosed. 

Fig. 3. — Low power, showing area of degeneration in piled-up epithelial surface. 
Basement -membrane, both layers gone; cornified layer still on the surface; pigmentation 
as result of hemorrhage. 

Fig. 4 shows a peculiar hyaline change beginning in the epithelial cell. It is the early 
stage of the degenerative process, and shows in the slide a peculiar run-together appear- 
ance. Blood-vessel wall shows proliferated endothelium. Some keratohyaline degen- 
eration. 



KERATOSIS. 611 

homogeneous substance, keratin, into which the original proto- 
plasm of the cell has been converted. Between the superficial 
flattened squamae, of which there are several layers, and the 
deepest germinal layer the cells have an intermediate character. 
The presence of keratin in this cornified tissue and the cells be- 
neath is not necessarily significant, as it is present in the normal 
structure and is the basis of horny tissue. No doubt the decom- 
posed keratin has something to do with the peculiar reaction of 
the tissue to stain, as keratin is a complex substance, which when 
decomposed yields leucin and tyrosin. When pathologically altered 
it would no doubt give a different chemical reaction to stain. 
Besides the resemblance to chronic specific disease there is also a 
marked resemblance, microscopically, to the condition known as 
Paget' s disease of the nipple. While, to be sure, one is a disease 
involving the skin epithelium and the other a disease involving 
the mucous-membrane epithelium, yet the physiological and his- 
tological law controlling these structures is largely the same. The 
similarity of the surface keratosis, the peculiar subepithelial con- 
nective-tissue alteration, is strikingly similar as compared with 
carcinoma, especially the pearl variety. It looks as though in 
one case the epithelial cells grew and penetrated down into the 
tissue, while in the other the tendency was toward the surface. 
These masses of keratinized epithelium are really pushed up from 
below, penetrating the basement-membrane. In other instances, 
as shown in Plate II, Fig. 9, the change has involved the entire 
epithelial surface so as to denude the papillae of the connective 
tissue. 

Hyaline change is also shown in the wall of the blood-vessel 
and in the connective-tissue papillae. In several sections, as in 
Plate I, Fig. 2, masses of hyaline degeneration show just beneath 
the basement-membrane and extend deeply into the submucosa. 
The masses on the surface, which appear at first inspection to be 
fibrin, I believe to be cornified epithelial cells bearing very much 
the same relation to the submucosa and adjacent structures as a 
finger-nail does to a finger. It does not react to the stain for 
fibrin, neither does it show leucocytes entangled in the meshes ; 
in fact, practically no cell infiltration except in one or two areas 
where there has been hemorrhagic infiltration. In several in- 
stances, as shown in Plate II, Fig. 7, these fingers of cornified tissue 
penetrate deeply into the submucosa or, rather, have their origin, I 
think, in the submucous connective-tissue papillae or genetic layer 
of the mucous membrane, and the longitudinal sections of such 
areas look very much like a section of a dead hair-bulb. Plate I, 
Fig. 3 has distinct areas of hemorrhagic infiltration with degen- 
eration, involving not only the submucosa, but extending up 
through the epithelial surface. 

From the sections examined the degenerative change seems 
to be largely hyaline. The process of degeneration is controlled 



612 DISEASES OF THE PHARYNX. 

by nutrition, and why we have hyaline degeneration in one condi- 
tion and fatty in another can only be explained from the stand- 
point of chemical pathology. That the tissues and fluids under 
certain chemical conditions bring about definite pathological changes 
is governed by the same general laws controlling chemical reac- 
tion. 

Bacteria of the throat found in diseased conditions may be 
only associated etiological factors. In mycosis, where so many 
bacteria are found, their import is lessened. The life and growth 
of the bacteria is largely determined by the character of the secre- 
tion. It may be that owing to the peculiar chemical change in 
the tissue requisite to the pathological alteration, as shown in 
mycosis, the chemistry of the secretion is suitable to the growth 
of the leptothrix. 

Symptoms. — The symptoms are irregular and depend some- 
what on the location of the tufts, there being no definite pathog- 
nomonic symptoms. When occurring on the tonsil, with no in- 
volvement of the pillars, there will be practically no symptoms, 
and the patient will not be aware of the existence of the disease 
until discovered by accident or while examining for some other 
condition. If the disease is located in the region of the fauces 
there is experienced a sensation of scratching with a certain 
amount of stiffness, especially during the act of swallowing, and 
after eating the patient may experience a sensation as if something 
had lodged on the pharyngeal wall. If the pillars are involved 
and the growths are prominent and come in contact with the sur- 
rounding parts, it will give rise to the sensation of a foreign body 
in the part. If the base of the tongue is involved there will be 
more or less coughing and hawking, giving rise to irritation about 
the epiglottis and the vestibule of the larynx with subsequent 
accumulation of mucus. 

The disease occurs in several forms, which are, no doubt, in 
part due to the location of the deposit and the age of the process. 
Thus, we have minute pinpoint-like, intensely white spots, on a 
level with the mucous membrane, of which they seem to form a 
part ; then the broad plaque-like white masses, projecting above 
the surface of the mucous membrane, seen most frequently on the 
pillars and lateral walls of the pharynx ; and lastly, the conical or 
triangular horny projections from the mucous membrane, pro- 
truding from two to eight millimeters above its surface. These tufts, 
or quills, are the most frequent and most characteristic manifest 
lesions of this disease. Quills so disseminated over the faucial 
and pharyngeal mucous surfaces, projecting out as distinctly 
bright points from the tonsil, pillars of" the fauces, lingual tonsil, 
and the glosso-epiglottic folds, with the mucosa from which they 
grow showing no evidence of inflammatory activity, present a 
most characteristic picture. The tufts are small, tough to horny 
hardness, firmly adherent to the mucosa, from which they can be 



PLATE II. 




Fig. 5 shows piled-up cornifled epithelium. "Basement-membrane shows slight change. Blood 
vessel walls slightly changed. 

Fig. 6 shows apparent fibrous-tissue formation which is keratinized epithelium and extends 
out over the surface. 

Fig. 7.— Submucous mass resembling dead hair-bulb, as described by Heryng. 

Fig. 8 shows broken-down fibrin and leukocytes piled up on the surface of the hardened epi- 
thelium. Some hyaline degeneration in the subepithelial structure, with a distinct break in the 
mucous membrane. 

Fig. 9 shows epithelial surface with cornified layer of epithelium ; also areas of degeneration 
in the submucosa directly beneath the piled-up epithelial layer. The genetic layer of the base- 
ment-membrane is very thin, and the connective-tissue layer is almost obliterated. 



PULSATING ARTERIES OF THE PHARYNX. 613 

separated only with difficulty, and when removed from the living 
tissue they do not undergo disintegration. The firmest, hardest, 
and most elongated quills grow from the base of the tongue and 
the crypts of the tonsils. Those growing about the isthmus of the 
fauces are frequently surrounded with a soft pultaceous substance ; 
those found at the base of the tongue and the pharynx are usually 
without this addition. The most frequent seat of what is known 
as keratosis pharyngis is Waldeyer's lymphatic chain, although 
the condition is not limited solely to this region. The growth is 
most abundant on or about the tonsils and at the base of the 
tongue. Frequently the tonsil will be studded with a half-dozen 
or more distinct tufts, while between the pillars and the tonsil and 
at the upper fornix will be found a continued succession of tufts, 
making almost a continuous white line. Over the base of the 
tongue they are often observed in ideal representation, which 
is, no doubt, due to their protection. Often we find tufts 
on the glosso-epig;lottic folds and in the glosso-epiglottic fossae. 
We have observed these also quite frequently on the lateral wall 
of the pharynx, on the epiglottis, and at the vault of the pharynx. 

Diagnosis. — In pharyngomycosis there may be slight febrile 
reaction, while in keratosis there is none. The disease has a pecu- 
liar tendency to undergo spontaneous resolution. It may last for 
several years or may undergo resolution in a few months. 

In keratosis the tufts are almost invariably distinctly pearly 
and of a waxy-white appearance, while in pharyngomycosis they 
are more likely to be yellowish and discolored. 

In pharyngomycosis the growths when removed rapidly un- 
dergo disintegration, while in keratosis the growths can be pre- 
served and sections made. 

In pharyngomycosis, I believe, the disease can be transmitted 
by direct inoculation of the crypts, while keratosis, I do not be- 
lieve, can be transmitted by inoculation. 

One form consists of wedge-shaped and triangular projections 
which extend quite deeply into the parenchymatous coats. These 
forms have a uniform glassy, yellow appearance. The masses are 
larger and entangled with epithelial plates and granular debris. 
The upper layer consists of finely granular masses, but no lepto- 
thrix. 

Treatment. — The most satisfactory treatment is the actual 
cautery, or else thorough curetment followed by the application 
of chromic acid (20 to 40 per cent.). 

PULSATING ARTERIES OF THE PHARYNX. 

Occasionally, irregularities in the contour of the posterior lateral 
walls of the pharynx are attended by anomalous distribution of 
the blood-vessels. The branches of the ascending pharyngeal may 
be unusually large, or the ascending pharyngeal artery itself show 



i 



614 DISEASES OF THE PHARYNX. 

distinctly in the wall of the pharynx. This gives rise to the pul- 
sating artery, owing to the fact that the blood-vessel has no muscu- 
lar support, and also that owing to its superficiality and the liability 
of the surrounding membrane to inflammatory conditions, there is 
a marked tendency to aneurysm when such an anomalous condition 
occurs. Fortunately the condition is very rare, but, when it does 
occur, produces symptoms irritating to the patient. I have observed 
only four cases in my private practice and hospital service. It 
gives rise to the sensation of a movable foreign body in the phar- 
ynx, with a constant tendency to effect its removal by forcibly 
clearing the throat. The only danger arising from this condition 
is (if the walls are altered and an aneurysm occur) a possibility 
of the rupture of the aneurysm, although in all cases this saccular 
dilatation does not occur, but when it does occur should then be 
classed under pharyngeal aneurysm. The pulsating artery of the 
pharynx then should really be classed in two varieties : First, pul- 
sating artery, in which no change has taken place in the wall, and 
second, the pulsating artery with aneurysm. There is practically 
no treatment which will be of any service toward affording relief. 

PHARYNGEAL ANEURYSM. 

In the pulsating artery of the pharynx the blood-vessel, while ab- 
normally placed, is physiological and has undergone no pathological 
changes in the wall-structure. However, as the vessel is illy-sup- 
ported and the surrounding delicate mucous membrane is likely 
to be involved in inflammatory processes, it is not unlikely that in 
such cases there should be a weakening of the blood-vessel wall 
and an aneurysmal sac formed. Such cases have been observed 
and reported. 

ANEMIA OF THE PHARYNX. 

In anemia where, from the poor nutrition, there is lessened vas- 
cular tone, with relaxed blood-vessel walls, as well as a lowering 
of the tone of the muscular tissue, which in turn fails to furnish 
support to the blood-vessel, all connective-tissue structure will be 
relaxed. This is especially true of the tissue which is backed up 
by bony framework and is practically devoid of support. The 
relaxed vessels will permit of leakage from the arterial system, and 
by reason of the lessened vascular tone there will be damming up 
of the venous system, while leakage will also occur from the veins. 
The high vascularity of the pharynx renders it especially liable to 
this local manifestation of a constitutional condition, and it will 
present a relaxed, flabby appearance. Although the tissue may be 
slightly edematous, it will be pale in color, and coursing over the 
surface and within the tissue will be seen dilated, tortuous vessels. 
The symptoms produced will resemble closely those of a simple 
chronic pharyngitis in its early stage. With the relaxation of the 
pharyngeal structure will be coupled a relaxation of the soft pal- 



NEUROSES OF THE PHARYNX. 615 

ate, giving rise to elongation of the uvula, really due to relaxa- 
tion of the surrounding structure, allowing the uvula to drag down 
against the pharyngeal wall and produce mechanical irritation. 
The secretion will be profuse and of rather a watery nature — 
rarely ever thick and tenacious. The pathological alteration in 
the structure is not marked, as is proved by treatment. For when 
such condition exists, if proper medication is directed toward the 
underlying cause, with improvement of the patient's general con- 
dition, the pharyngeal symptoms entirely disappear, and the tissue 
returns to the normal. The condition is most frequently observed 
in females, especially those of the lymphatic temperament, although 
sex is not the etiological factor, except that anemia is more com- 
mon in the female than in the male. The relaxed pharyngeal 
structure gives rise to a sensation closely akin to that of the pres- 
ence of a foreign body in the throat. There is a constant desire 
to swallow, and the act of swallowing affords no relief. The con- 
dition is not one of inflammation. 

Ulcers. — This form of ulcer occurs associated with some gen- 
eral condition in which the vitality is very much lowered. Inter- 
ference, then, with the peripheral circulation may cause the ulcer- 
ated condition. These ulcers may appear on the pharyngeal wall 
or on the tonsillar surface. The ulcer lacks the acute phenomena 
of an infected ulceration, and is usually small and localized. The 
secretion is scanty. The ulceration described in these anemic cases, 
while it is purely local, comes under the systemic group of diseases. 

The cure can only be effected by directing treatment toward 
the underlying cause or systemic condition. In other words, the 
ulcer is an associated condition and not a separate one. 

Treatment. — Local treatment is of no avail, other than the 
use of cleansing solutions to keep the surface clear of mucus. 
Astringents will give temporary relief, but a permanent cure can 
be affected only by the internal administration of such remedial 
agents as are indicated by the underlying cause producing the 
anemia. The treatment of the condition, in reality, does not 
belong to the specialist. 

NEUROSES OF THE PHARYNX. 

1. Anesthesia. 5. Neuroses of motion. 

2. Hyperesthesia. a. Spasm. 

3. Paresthesia. 6. Paralysis. 

4. Neuralgia of the pharynx. 

Anesthesia. — This is a rare affection, and is characterized 
by an inability to feel the bolus of food, some portions of which 
remain in the pharynx or are drawn into the lungs. 

Etiology. — Anesthesia that is transient and local may be 
brought about by the ingestion of morphin or the bromids in large 



616 DISEASES OF THE PHARYNX. 

quantity, or by induced local anesthesia. It is usually found as 
consequent to ulceration, in which fibrous-tissue formation has 
obliterated the terminal nerve-filaments, as is seen in the specific 
inflammations and diphtheria ; or it may be the result of progres- 
sive bulbar paralysis. It may occur, however, in hysteria, in 
some cases of general paralysis of the insane, and in epilepsy, 
typhus fever, and cholera. 

Prognosis. — The outlook depends entirely upon the cause. 
If the condition is dependent upon acute disease or diphtheria, or 
attended by hysteria, the prognosis is more favorable than in the 
other instances ; although, if scar-formation be extensive, the re- 
sulting contraction will leave permanent alterations in sensation. 

Treatment.— In cases in which cure can be expected, or in 
any instance, perhaps, the administration of strychnin in heroic 
doses or the employment of the galvanic current is indicated. It 
may be found necessary to feed with a stomach-tube. 

Hyperesthesia. — Hypersensitiveness of the pharynx is com- 
mon, and may exist along with acute inflammation in persons given 
to excessive use of tobacco or alcohol. It may be due to elon- 
gation of the uvula or a manifestation of hysteria, and may some- 
times occur without assignable cause in persons of perfect health. 
In some cases the hyperesthesia may be of such an extent as to 
interfere with swallowing. Usually the condition is called into 
prominence when an attempt is made to examine the throat with 
the laryngeal mirror. 

The internal administration of potassium bromid, the inhalation 
of a solution of 20 grains to the ounce of the same drug, the em- 
ployment of cocain or eucain, 4 to 10 per cent., or the sucking of 
ice for fifteen minutes will render the pharynx less sensitive and 
more amenable to treatment and examination. For the hypersen- 
sitiveness of acute inflammation troches of slippery elm may be 
employed, or a protective balsamic preparation of compound tinct- 
ure of benzoin and 50 per cent, boroglycerid, in equal quantities,, 
may be applied. 

Paresthesia. — Sensations that are abnormal to the pharynx 
may resemble heat, cold, irritation as by a foreign body, or swell- 
ing. 

Etiology. — Often, after the successful removal of a foreign 
body from the pharynx, the patient insists, even for months, that it 
is still present, because the inflammatory irritation to the peripheral 
nerves, caused by its actual presence, persists even after removal.. 
Abnormalities of sensation occur in hysterical females. Enlarge- 
ment of the follicles of the pharynx or lingual tonsil causes a num- 
ber of peculiar ill-defined perversions of sensation in the pharynx. 

Prognosis. — The prognosis as to a speedy cure should be 
guarded, as the affection, despite the best of treatment, may exist 
for months. 



NEUROSES OF THE PHARYNX. 617 

Treatment. — Puncture the enlarged follicles with a blunt 
probe and apply an astringent, such as glycerole of tannin, or 
employ the galvanocautery carefully. Bromid of soda internally 
in 10-grain doses may be employed in the cases of neurotic origin. 
Menthol in albolene, 1 5 grains to the ounce, as a spray, may be 
employed in the cases due to foreign bodies. If a rheumatic 
tendency is present, use salicylate of soda or citrate of lithia, 
5 grains thrice daily. 

Neuralgia of the pharynx is due to the same causes as 
paresthesia of the pharynx. The symptoms of neuralgia are closely 
akin to those caused by that affection, with the addition of actual 
pain. The same causes that produce neuralgia elsewhere may be 
responsible, too, for the condition in the pharynx. In anemic or 
chlorotic women the affection may be bilateral or involve only one 
side. 

The treatment depends entirely upon the cause, with the addi- 
tion of local applications of sedative solutions. 

Neuroses of Motion. — Synonyms. — Clonic spasm of the 
pharynx ; Pharyngeal nystagmus. 

a. Spasm. — Acute inflammation of the fauces, hydrophobia, 
lyssophobia, cerebral disease, chronic pharyngitis, hysteria, or 
epilepsy may cause spasm of the pharynx. 

The spasmodic ejection of food on attempted swallowing may 
occur without warning. 

The condition should be differentiated from stricture or paralysis 
of the esophagus or paralysis of the pharynx. In stricture of the 
esophagus there is difficulty in swallowing, but the forcible eject- 
ment of food is not observed. Passage of an esophageal bougie 
will aid in the diagnosis. In paralysis of the pharynx or esoph- 
agus the food is not suddenly and forcibly thrown from the mouth, 
though there is difficulty in swallowing it. The spasm may occur 
at intervals covering weeks or months, and may eventually neces- 
sitate rectal alimentation. The employment of tonics, .such as 
the double sulphid of arsenic or lactate or phosphate of iron, is 
indicated. Xerve sedatives, such as the bromids of soda and 
potassium or zinc valerianate, may be of use in allaying the spasm. 

b. Paralysis. — Paralysis of the pharynx may be unilateral or 
bilateral ; may involve one or all of the constrictors. 

Etiology. — Acute or chronic bulbar myelitis, embolism, hemor- 
rhage, tumors, or basilar meningitis may cause the condition by 
their involvement of the central areas in the medulla that govern 
the pharynx. Syphilis, tuberculosis, cerebrospinal meningitis, or 
sunstroke may produce a similar result. It is found along with 
facial paralysis, and is frequently observed as a sequel of diph- 
theria. If occurring during the course of acute febrile disease, 
the prognosis is rendered excessively grave. It may be one of 
the earliest symptoms of the disease described by Duchenne as 



618 DISEASES OF THE PHARYNX. 

glossolabiolaryngeal paralysis or progressive bulbar paralysis. The 
causes above enumerated act by their paralyzant effect on the 
nerve-supply to the pharynx, either centrally, during the course 
of the nerve outward, or by peripheral involvement. 

Symptoms. — The most characteristic symptom of the condition 
is difficulty in swallowing, causing accumulation and dribbling of 
saliva. Attempts at swallowing are accompanied by contortion 
of the muscles of the neck and face, and, even if the attempt at 
deglutition is at first apparently successful, fluids may run into 
the trachea, due to attendant paralysis of the glottis, and excite 
cough or spasm of the glottis. The facial expression on attempted 
swallowing is that of extreme pain combined with sorrow, while 
in repose the face is placid. If the soft palate is involved, food 
may be forced into the posterior nasal cavity by the efforts of the 
tongue to assist deglutition. 

The symptoms of acute bulbar paralysis referable to the 
pharynx are often overshadowed by the gravity of those observed 
in other organs. Unsteadiness of gait, dizziness, headache, inter- 
ference with phonation and respiration rapidly progress in the 
great majority of cases to a fatal termination. Progressive bulbar 
paralysis has a group of symptoms peculiarly its own, slowly but 
surely tending toward death. Beginning usually with implication 
of the tongue, the lips, pharyngeal and laryngeal constrictors are 
rapidly involved. Difficulty in articulation gradually merges into 
mumbling. Atrophy of the tongue follows, causing great difficulty 
in mastication and deglutition. Food collects between the cheeks 
and gums. Labial and dental sounds cannot be pronounced. 
Saliva dribbles from the corner of the mouth or may trickle with 
the food into the larynx, setting up violent spasms of gagging and 
coughing, or may give rise to a fatal septic pneumonia. Diphthe- 
ritic paralysis of the pharynx may be due to central toxemia or 
peripheral nerve-necrosis, and may involve one or both sides with 
the adjacent structures. Dysphagia, regurgitation of food through 
the nose, blunting of smell and taste, liability of food to pass into 
the larynx because of paralysis of the epiglottis, with an inability 
to expel the accumulated mucus, are the chief symptoms. 

As a complication of facial paralysis, involvement of the 
pharynx occurs if the cause of the condition be situated above the 
geniculate ganglion (Porcher), and the symptoms do not vary from 
those already given for diphtheritic paralysis, except by the added 
involvement of other structures. 

Diagnosis. — The condition may be recognized and differen- 
tiated by the clinical history and symptoms just described. 

Prognosis. — If due to diphtheria or temporary cause, or if 
attended by facial paralysis, the outlook is not especially grave. 
If occurring late in the febrile diseases or in progressive bulbar 
or acute bulbar paralysis, the prognosis is almost always fatal. 



FOREIGN BODIES IN THE PHARYNX. 619 

Treatment. — In all cases thick soups or jellies should be given. 
If this cannot be swallowed, the stomach-tube or rectal alimen- 
tation should be resorted to. Give a quart of milk and three raw 
eggs beaten together, beef-tea or broths, twice daily through the 
stomach-tube, or inject into the rectum slowly and carefully 8 
ounces of any of these foods or liquid peptonoids three or four 
times daily. For aciite bulbar paralysis local blood-letting, free 
catharsis, and ice-bags to the nape of the neck may be employed ; 
internally, the administration of alteratives. Strychnin in enor- 
mous doses should be given, and the effect carefully noted. No 
treatment is curative for chronic bulbar paralysis. 

If due to diphtheria, nitrate of strychnin, grain ■£$, three 
times a day to an adult, may be cautiously increased until twitch- 
ing of unaffected muscles is produced, when the dose should be 
decreased until this symptom disappears. Galvanism or faradism 
should be employed, with both electrodes over the affected mus- 
cles, for ten minutes every other day. Arsenic in the form of 
Fowler's solution, in 5- to 10-drop doses three times a day, may 
be employed with advantage. Tonics, such as iron, quinin, or 
some malt preparation may be used to advantage. Change of air 
and scene will prove beneficial. 

FOREIGN BODIES IN THE PHARYNX. 

The persistent lodgement of a foreign body in the pharynx or 
tissues above and between it and the oral cavity, with a conse- 
quent difficulty in its accurate location and extraction, is of fre- 
quent occurrence. The lodgement may be due to the size and 
shape of the body, or its shape alone. Taken in with food or by 
accident, small fish-bones, pins, needles, and sharp objects, spiculse 
of bone, false teeth, coins, marbles, buttons, and nut-shells have 
become lodged in or about the pharynx. The sharp or pointed 
articles usually become embedded in the spongy tissue of the fau- 
cial or lingual tonsils, and the smaller, irregularly pointed objects 
may find lodgement in the pyriform sinus, the posterior pharyn- 
geal wall, or at the entrance of the esophagus. The smooth bodies, 
either large or small, as a rule, pass into the esophagus, lodging 
at the prominence of the cricoid cartilage. 

The sharply pointed articles, as well as those that are small in 
size, like spicule of bone, etc., if not removed within a short time 
may set up inflammation and suppuration, or, piercing the tissues, 
becomes encysted, or may even migrate to other localities in the 
neck and be removed without suppuration from beneath the skin. 
Pus may, however, form occasionally at their point of exit. The 
symptoms arising from this class of foreign bodies are pain in the 
region affected, although this symptom may not be referred to the 
actual location of the body, but, being reflected elsewhere, may 



620 DISEASES OF THE PHARYNX. 

prove misleading ; cough and retching may also be reflexly trace- 
able to the presence of the irritating material. The larger bodies 
give rise to symptoms dependent upon their location. If caught 
low down in the pharynx, about or within the entrance to the 
esophagus pain on swallowing is a prominent symptom ; if press- 
ing on the larynx, the voice may be affected. There may be 
cough, expectoration, and in children convulsions, or in adults 
convulsive movements of the fauces may occur. Frequently the 
patient will give you entirely the wrong impression as to the site 
of the foreign body, the sensation produced in his throat giving 
him a wrong impression. I have seen cases in which the patient 
would, from his standpoint, tell you exactly the location of a 
foreign body, as a fish-bone, and the bone was afterwards located 
at least two inches from the site which he had detemined. I 
have also noticed, especially with fish-bones, that frequently the 
bone is lodged behind the soft palate, and in one case the 
sharp-pointed bone had penetrated the soft palate and impinged 
against the pharyngeal wall during the act of swallowing. 

In locating the foreign body the patient should be directed to 
open the mouth as easily and naturally, as possible, and the cavity 
of the mouth and its aclnexa should be inspected first without the 
use of the tongue-depressor, mirror, or other aid to vision. In this 
way spasm of the muscles of the pharynx or fauces, with either the 
firmer embedding of the body or its involvement in the faucial 
folds, may be avoided, especially if the object sought be small, as a 
fish-bone. Failing in this procedure to locate the body, the parts 
may be cocainized, and inspected by the aid of the laryngeal mirror. 
If the object sought be large and smooth, the patient should be placed 
upon his back to facilitate examination, lessen any interference with 
breathing, and prevent further entrance into the respiratory or ali- 
mentary tracts while efforts are being made toward its removal. 
The finger should be swept methodically over the surface, com- 
mencing at one side and travelling in parallel lines to the other 
until the entire space is covered. Cotton, loosely wrapped on a 
probe, may serve to locate the body by entangling it in the meshes 
of the cotton. Curved forceps, guided to the body by the unaided 
eye, by the mirror, or by the finger, will generally remove it. It 
is to be remembered that the irritation once produced by the pres- 
ence of a foreign body will persist for a time after its removal, 
and will lead the patient in some instances to believe that it has 
not actually been taken aw T ay. A boric-acid wash, 10 grains to 
the ounce, or 50 per cent, boroglycerid and compound tincture of 
benzoin, applied to the site of injury, will allay this feeling and 
assist healing. 



CHAPTER XIX. 

DISEASES OF THE LARYNX 

Method of Laryngeal Examination — Autoscopy ; Inspection of the Pos- 
terior Wall of the Larynx. 
Malformations and Deformities. 

1. Congenital. 

a. Stenosis. 

b. Dilatation or Pouch (Laryngocele)* 

c. Hypertrophies. 

2. Acquired Malformations. 

a. Stenosis. 

1. Tubercular. 

2. Syphilitic. 

3. Lupus. 

4. Traumatic. 
Acute Inflammatory Diseases. 

1. Cough. 

2. Acute Catarrhal Laryngitis. 

3. Acute Catarrhal Laryngitis in Constitutional Diseases. 

a. Erysipelas. 

b. Measles. 

c. Scarlet Fever. 

d. Small-pox. 

e. Typhoid Fever. 
/. Typhus Fever. 
g. Influenza. 

h. Miasmatic Epiglottis. 

i. Rheumatism. 

j. Purpura Hemorrhagica. 

4. Acute Laryngitis in Children. 

5. Laryngismus Stridulus. 

a. Congenital Stridor. 

b. Spasm of the Larynx in Children. 

c. Spasm of the Larynx in Adults. 

d. Spasmodic Laryngitis. 

6. Acute Epiglottitis. 

7. Traumatic Laryngitis. 

8. Suppurative Laryngitis. 

9. Rheumatic Laryngitis. 

10. Edematous Laryngitis. 

a. Chronic Edema of the Larynx. 

11. Membranous Laryngitis. 

a. Croupous. 

b. Fibrin oplastic. 

12. Hemorrhagic Laryngitis. 
Chondritis and Perichondritis. 
Simple Chronic Inflammations. 

1. Simple Chronic Laryngitis. 

2. Follicular Laryngitis. 

3. Dry Laryngitis. 

4. Cyanotic Laryngitis. 

5. Hyperplastic Laryngitis. 

6. Scleroma of the Larynx. 
Anemia of the Larynx. 
Hyperemia of the Larynx. 
Pemphigus of the Larynx. 

621 



622 DISEASES OF THE LARYNX. 

Singers' Nodules. 

Specific Inflammations of the Larynx. 

1. Syphilis. 

2. Tuberculosis. 
Laryngeal Hemorrhage. 
Bronchoscopy. 

Foreign Bodies in the Larynx. 

Prolapse of Laryngeal Ventricles. 

Voice, Speech, Defect of Speech, and Kelation of Voice to Hearing 

(Chapter XX.). 
Neuroses of the Larynx ( Chapter XXI. ) . 
Intubation (Chapter XXII. ). 
Tracheotomy (Chapter XXIII. ). 
Surgery of Larynx (Chapter XXIV.). 

METHOD OF EXAMINATION. 

For the purpose of examining the larynx there are two ele- 
ments essential — light and the laryngeal mirror. Full reference 
has been made to the best methods of illumination under the 
chapter on Diseases of the Nose, and does not necessitate 
repetition. In examination of the larynx a steady hand with 
delicacy of touch and a well-trained eye are absolutely essential. 
The patient, placed in the position as described in Chapter II., 
page 34, should be thoroughly acquainted with what is expected 
of him, so as to insure his co-operation, as he can be rapidly 
educated to aid materially in laryngeal inspection. He should be 
taught to breathe quietly and naturally, and gradually let the jaw 
drop, leaving all the parts relaxed. By so doing, the buccal and 
pharyngeal cavities can be inspected, and a survey of the entire 
area will guide the operator as to the best method of proceeding 
with the laryngeal examination. As a rule, a better view can be 
obtained by having the patient protrude the tongue as far as pos- 
sible, when it should be firmly grasped between the thumb and 
index finger, preferably by the patient, thereby avoiding the 
danger of forcible traction on the tongue or injury from the teeth. 
It must be remembered, however, that upon the shape of the 
pharynx and the entire buccal cavity will depend largely the 
method of laryngeal examination. In some individuals a per- 
fect examination can be made without the aid of the tongue-de- 
pressor or even protrusion of the tongue. In others with a very 
sensitive pharynx, the mere protruding of the tongue or the 
attempt to insert the mirror into the mouth will bring on violent 
retching and gagging. The plan I usually follow, and the 
one I find very successful in laryngeal examination is, after 
thoroughly explaining to the patient what is expected of him, 
to give him a small hand-mirror and ask him to watch the 
manipulation. In many cases in which the mention of a laryn- 
geal examination would almost produce gagging, I have found 
that the patient, by becoming interested in watching his own 
pharynx, will permit a satisfactory examination without the 
slightest inconvenience. Any person can be taught to depress the 



METHOD OF EXAMINATION. 



623 



back portion of the tongue and control the muscles so as to produce 
a concave instead of a convex surface, and as he is better able to 
control his efforts by visual aid, the mirror is of great advantage. 
Equally good results can be obtained by having the patient close 
his eyes during the entire procedure. If, however, he begins 
to gag, the examination should be stopped at once, the patient 
allowed to close the mouth and either to engage in conversation 
or allowed to take a drink of water to relax the muscles and 
relieve spasm. In the manipulation of the mirror the utmost 
care should be taken not to touch the pharyngeal wall, or, in fact, 
any sensitive structure ; but if the construction of the pharynx is 
such that the larynx cannot be seen without placing the mirror 
directlv against the soft palate and uvula, the pressure by the mir- 
ror should be made at once, and, although not roughly, with firm- 
ness. This procedure will produce less gagging and spasm than if 





Fig. 218. 



Fig. 219. 



Fig. 218 —Front view of the larynx : 1, Hyoid bone ; 2, greater cornu ; 3, small cornu ; 
4, lateral thyrohyoid ligament ; 5, nodular cartilage ; 6, middle thyrohyoid ligament ; 7, 
thyroid cartilage ; 8, superior horn ; 9, inferior horn ; 10, cricoid cartilage ; 11, cricothyroid 
ligament : 12, crico-arythyroid ligament ; 13, first and second rings of trachea. 

Fig. 219.— Rear view of the larynx : 1, Thyroid cartilage ; 2, superior horn ; 3, inferior 
horn ; 4, cricoid cartilage ; 5, cricothyroid ligament : 6, arytenoid cartilage : 7, prominent 
external angle of the base into which crico-arytenoid muscles are inserted ; 8, epiglottic 
cartilage ; 9, thyro-epiglottic ligament ; 10, posterior membrane of the trachea. 



it is gently touched against the soft palate or pharyngeal wall. In 
many cases where examination of the larynx in the sitting posture 
is quite difficult, if the patient is asked to stand up, incline the 
body slightly forward, and draw, the tongue out firmly, and the 
mirror is inserted directly against the soft palate by the examiner, 
who remains seated, a perfect view of the larynx may be obtained. 
If the examination is a prolonged one, it is better to allow the 



624 



DISEASES OF THE LARYNX. 



patient to rest repeatedly, as the continued forced and unnatural 
position of the muscles rapidly becomes uncomfortable to the 
patient, and much better results will be obtained than by contin- 
ued and enforced examination. It is much better to examine the 
larynx without the use of cocain to allay irritability, as the normal 
condition of the tissue can be better appreciated than when it is 
influenced by a local anesthetic. One of the great difficulties in 
laryngeal examination is met with in a buccal cavity that is 
elongated and narrow, with a thick and muscular tongue. Oc- 
casionally, and especially is this true in children, an enlarged 




Fig. 22U- Showing position of the tongue-controller and laryngoscope in examination of 
the vocal cords and larynx. Epiglottis, cords, and arytenoids are shown in the mirror. 



tonsil forms a marked obstruction. As a rule, where the tongue 
is thick and muscular, the use of the tongue-depressor de- 
scribed on page 39 will answer much better than attempts to 
drag the tongue forward. Fig. 220 shows the mirror and tongue- 
depressor in position. If the tongue-depressor is used with- 




Fig. 221 — Laryngoscopy image during respiration. 




Fig. 222.— Laryngoscopic image during phonation 




Fig. 223 —Laryngoscopic appearance of chronic inflammation. The cords lack luster: the 
pericordal tissue is inflamed; the epiglottis is notched, the result of ulceration. 



METHOD OF EXAMINATION. 625 

out any force, gradually allowing the muscles to relax, a good 
view of the larynx can be obtained. During the examination, 
should the patient show an inclination to gag, if he is asked to 
take quick, short, almost panting respirations, a good view of the 
cords may be obtained, and any irregularities in structure or motion 
can be easily detected. The rapid forced respiration brings the 
cords into rapid play ; besides, gagging will be avoided. Yet in 
many cases a good view of the larynx may be obtained if the 
patient is asked to breathe quietly, allowing all the parts to be 
relaxed. The position and relation of the cords can also be demon- 
strated by directing the patient to say " ah " or " eh." 

The size of the mirror to be used will be determined by the 
anatomical relations of the part. The same may be said of the 
angle that the mirror is to be placed to the handle, which will 
vary for different individuals. The proper angle can be obtained 
by bending the mirror rod. In making an examination with the 
mirror,- the fact must not be overlooked that the position of the 
parts is reversed, as this is highly important when laryngeal 
applications are to be made. 

While some authorities insist that the mirror should rest on the 
posterior wall of the pharynx, having first pushed up the soft 
palate and uvula, so that the instrument will come in contact with 
the less sensitive structure of the nasopharynx, the method is not 
applicable in all cases ; in fact, in a very small proportion of the 
cases will it be found successful. In a large number of persons 
the examination can be made without touching the .pharyngeal 
wall ; besides, the difference in degree of sensitiveness of the struct- 
ures of the pharynx and nasopharynx is very slight, even when the 
tissue is in a normal condition, and, as a rule, when laryngeal exam- 
ination is necessary, it is always attended by some pharyngeal and 
nasopharyngeal lesion, so that while the sensitiveness of the parts 
might vary omewhat, yet that variance would not be sufficient to 
be of any considerable importance from the standpoint of examina- 
tion. In using the laryngeal mirror the epiglottis will be the first 
tissue observed, standing out prominently, its edges and surface 
showing differently in different individuals. In some it assumes 
a decidedly double concave appearance, with crescentic edge ; in 
others more nearly on a plane ; and again, rather V-shaped (Figs. 
221-223. The color varies in different stages of the examina- 
tion. The first glimpse will give most accurately the correct 
color, as muscular contraction, interfering with circulation, rapidly 
alters the surface appearance. There will be observed three folds 
of mucous membrane, which stretch from the lingual surface of the 
epiglottis to the base of the tongue. In some instances they 
resemble folds, while in others they are distinctly cord-like. 
These three bands form the glosso-epiglottic ligaments, and the 
two depressions formed between the three ligaments are known 
as the glosso-epiglottic or lingual fossce. The aryepiglottic folds, 

40 



626 DISEASES OF THE LARYNX. 

which really form the lateral walls of the larynx, are seen passing 
backward and downward from either side of the epiglottis to the 
arytenoid cartilages. The two arytenoids show as grayish-white, 
bulb-like prominences, the position of which varies during respira- 
tion and phonation. On either side of these folds will be seen the 
pyriform sinuses. At the posterior portion of the folds, close to 
and directly in front of the arytenoid cartilages, are two small 
prominences, one on either side, branches of the arytenoid carti- 
lage, and known as the " staff of Wrisberg." Each arytenoid car- 
tilage is strengthened and enlarged by the cartilages of Santorini. 
These, however, cannot be recognized with the laryngeal mirror, 
and can be demonstrated on the cadaver only by dissection. The 
arytenoid commissure passing between the two arytenoid cartilages 
forms the posterior wall of the larynx. Immediately behind the 
commissure will be observed the closed fissure which marks the 
orifice of the gullet. Thus we have the epiglottis in front, the 
aryepiglottic folds on either side, the arytenoid cartilages and 
commissure posteriorly. Directly below the aryepiglottic folds, 
on either side, will be distinctly seen the two ventricular bands or 
folds, as they are nothing more than folds of mucous membrane, 
extending from the angle of the thyroid cartilage in front to the 
base of the arytenoid cartilage behind. These folds of mucous 
membrane are somewhat thickened at the margin and are of a 
deeper color than the other laryngeal structures. They lie parallel 
with the vocal cords, which are directly beneath them, and 
change position with the movement of the arytenoid cartilages. 
The true vocal cords, which lie directly beneath the ventricular 
bands, show as tense bands of inelastic fibrous tissue, or rather 
tissue which is controlled by attached muscular tissue. The color 
of the vocal cords depends entirely upon the position assumed 
(Figs. 221, 222), as the greater the tension the paler and whiter 
the cord ; besides, the necessity of laryngeal examination is usually 
one of some diseased condition, and the cord will be influenced by 
the pathological alterations in the adjacent structure as well as 
by constitutional lesions. It may show a thickened, uneven sur- 
face, with dense injection and dull-red color ; however, normally 
it appears as a clear white band, becoming slightly more pinkish 
in color when relaxed. The width of the band is increased in 
attempted phonation. The entrance to the ventricle of the larynx, 
which is scarcely recognizable, lies between the ventricular bands 
and the true cords. It appears rather as a shaded line or depres- 
sion. 

Autoscopy. — As supplementing the laryngoscopic mirror in 
the examination of the larynx and trachea, we have the autoscope, 
with the added claims of direct inspection and view of the poste- 
rior walls of these important structures. Kirstein of Berlin is 
the inventor and perfector of this instrument, which consists of 



METHOD OF EXAMINATION. 627 

three parts — the spatula, the sliding hood, and the handle. The 
spatula is a slightly concave metal plate, 14 cm. in length, which 
is in the main straight ; but it is slightly curved downward toward 
its laryngeal end, where it has a somewhat thickened lip and 
rounded edges to prevent injury to the parts with which it comes 
in contact. The sliding hood serves the purpose of keeping 
the teeth, the lips, and in man the moustache, away from the 
spatula, leaving sufficient space between the two plates for inspec- 
tion and for the introduction of any instrument. The handle is the 
electroscope of Casper, which by means of its small electric light 
illuminates the entire length of the spatula and the parts beyond. 

The two main conditions upon which the autoscope depends in 
laryngeal inspection are — first, that firm pressure upon the root 
of the tongue and the median glosso-epiglottic ligament will 
elevate the epiglottis, thus giving the desired view ; and, second, 
that by proper position the laryngotracheal tube may be made to 
form a straight instead of an angular line with the axis of the 
buccal cavity. 

The technic of the examination is as follows : The physician 
stands before the patient, who is seated in a chair, with the neck 
inclining slightly forward. The autoscope is introduced in ex- 
actly the same manner as an ordinary tongue-depressor. A 
view of the buccal cavity and oropharynx is thus obtained. By 
pushing the spatula farther backward, elevating the handle, and 
pressing firmly downward and backward on the base of the 
tongue, being careful not to use the upper teeth as a fulcrum, the 
lower part of the pharynx, the larynx, and (if the patient's posi- 
tion be correct) the trachea may be seen. The actual tissues 
appear in autoscopy, not their image- with a remarkable distinct- 
ness of anatomical detail. Above all, the posterior wall of the 
larynx, the interarytenoid fold, which can be examined only with 
great difficulty by the aid of the mirror, can be inspected almost 
in a surface view, and the possibility of inspecting the whole of 
the trachea and the beginning of the bronchi should alone be 
sufficient to ensure for autoscopy recognition among diagnostic 
resources. 

Inspection of the Posterior Wall of the X,arynx. — 
Various devices have been employed from time to time in order 
to expose the posterior wall of the larynx to inspection, the fore- 
shortening of its image in the ordinary method of laryngoscopy 
often preventing due appreciation of existing lesions. 

The latest device is by Dr. Mermod of Iverdon. This con- 
sists in the use of a second mirror, which is placed within the 
cavity of the larynx, and which he appropriately calls a laryngen- 
doscope. Its reflecting surface is directed toward the reflecting 
surface of the ordinary mirror. A small, heart-shaped mirror, 
movable upon its shank and controlled by a screw 7 , is attached to 
the extremity of a laryngeal handle of the ordinary curve. 



628 DISEASES OF THE LARYNX. 

The illumination must be good in these cases, because the image 
has to be reflected from one mirror upon the other. 



MALFORMATIONS AND DEFORMITIES. 

The conformation of the larynx may deviate from normal either 
before birth or afterward by acquired disease. The congenital 
variations may be divided into stenosis, dilatation, and hyper- 
trophies. As to the actual cause of the variation in utero of the 
laryngeal structures from the normal, our knowledge is limited, 
yet it must be granted that parental disease or taint may bear 
at least a predisposing relation. Absence of the larynx is usually 
noted in monstrosities, where there is deficiency in development or 
overdevelopment in other organs. Malformations of the larynx 
may also consist in an extremely small organ. In individuals the 
formation of the larynx varies. 

Congenital Stenosis. — Arrested development of the larynx 
is often found along with imperfection of the genital tract, and, as 
the continuation of the respiratory apparatus is formed from the 
same source as the larynx, it is rare to find that organ maldevel- 
oped without some coexistent want of development in the lungs, 
trachea, or bronchi. Webs or bands stretching across the glottis 
are the most frequent forms of stenotic closure. These are found 
generally in the anterior commissure. The interarytenoid region 
is usually a seat of a different phenomenon — a cleft which may 
extend from the palate and epiglottis above and penetrate through 
the cricoid cartilage. This web usually binds together the vocal 
cords, sometimes the ventricular bands. Its color closely resem- 
bles that of the cords themselves. It is usually thin and easily 
torn, but may be elastic. There may be a family history of similar 
growths. An incomplete separation of the vocal cords anteriorly 
is occasionally seen and may not interfere with the voice. The 
congenital stenosis may exist for many years without attracting 
notice, until some intercurrent malady directs attention to the 
larynx. A papillomatous web uniting the vocal cords, causing 
aphonia, is reported by Morel! Mackenzie. 

Treatment. — Any obstruction to breathing, such as enlarge- 
ment of the faucial tonsils, adenoids, nasal polypi, or abnormal- 
ities of the septum, should be corrected. As to the treatment of 
the actual condition itself, the introduction of OT)wyer's tube may 
be sufficient. Should this means fail, the web should be cut by 
some such cutting dilator as seen in Fig. 224. The tube should 
be worn for several days after the operation, or should be passed 
at intervals. The fact that tracheotomy may be obligatory at any 
time should warn the surgeon to be ever prepared to perform the 
operation. The imminent danger to life from the closure of the 
glottis should cause any one who favors non-operative interference 



MALFORMATIONS AND DEFORMITIES. 629 

to weigh carefully the reasons for and against operation before 
non-interference has been decided upon. 

Dilatations or Pouches. — Laryngocele or pouching of the 
lining of the larynx, due to abnormal communications from with- 
out — extremely rare in man, although common in lower animals 
— may be due to congenital malformation and failure of union in 
portions of the thyroid cartilage. It may also form after necrotic 
processes, where portions of the cartilage have sloughed. 

Hypertrophies. — Elevations of normal tissues are occasion- 
ally observed in the anterior commissure or growing from the 
true vocal cords. These may be congenital or acquired. They 
are, in reality, hyperplasias. The cause of these growths is not 
definitely known. Mouth-breathing due to adenoids may lead to 
hyperemia, with increased nutrition. The irritation of the larynx 
may be responsible for the actual origin of the growths. Syphilis 
or tuberculosis may also have causal relation to them. The symp- 
toms consist in imperfect phonation, which may be coupled with a 




Fig. 224.— Whistler's cutting dilator. 

metallic cough that is persistent, or there may be associated 
attacks of actual spasm of the glottis. 

Treatment. — Treatment of these cases should consist in the 
removal of all obstructions to free breathing in the upper air- 
passages. The application of astringents or escharotics is to be 
condemned, and the former should only be resorted to in the event 
of complications preventing surgical interference. Spontaneous 
cure of these outgrowths may result after all source of irritation 
be removed, though this is exceptionally rare. The performance 
of a preliminary tracheotomy to afford physiological rest to the 
irritated structures might be justifiable in aggravated cases. 
Endolaryngeal ablation should be done with the greatest care, 
with guarded instruments, and under the strictest antiseptic 
directions. 

Acquired Stenosis. — Persistent narrowing of the laryngeal 
aperture may be due either to trauma or to constitutional causes. 

a. Cicatricial contraction or redundant granulation may pro- 



630 DISEASES OF THE LARYNX. 

duce stenosis. The active cause of such condition may be injury 
by foreign bodies, attempts at suicide by cutting the throat, the 
accidental or intentional swallowing of hot or caustic liquids, or 
inhalation of steam. The outlook is always grave, not only for 
the preservation of the vocal function, but also from the fact that 
the cicatricial contraction or edema may actually endanger the 
patient's life. The treatment should be adapted to each special 
case. Tracheotomy should always be performed if the stenosis 
is such as to threaten life. When the contraction of the cicatri- 
cial tissue is not active and the stenosis is not very great, the 
cutting dilator shown in Fig. 224, followed by the introduction of 
O'Dwyer's tube for a few hours daily, may eifect a cure. For a 
more extensive membranous involvement Schrotter's method by 
the knife or electric cautery may be adopted, with subsequent 
dilatation by means of bougies. Should either thyrotomy or 
tracheotomy be imperative, absolute rest of the voice ought to be 
insisted upon until the wound is healed. 

b. Stenosis due to syphilis in the larynx may form here as 
elsewhere and assume a variety of aspect. The narrowing may be 
due to chronic edema at any period of syphilitic lesion. 

In children, sudden acute severe dyspnea should always sug- 
gest the possibility of syphilitic edema and the application of the 
proper remedial agents. The commonest form of stenosis due to 
syphilis is that of a cicatricial web or band of varying thickness. 
These web-like bands may be found connecting the vocal cords 
and ventricular bands, or may unite one part of the larynx to 
another in its cicatricial involvement. Membranous synechia and 
fibrous bands of adhesion may form in the larynx following diph- 
theria, either due to ulceration and afterward fibrous tissue foi%. 
mation, or in some instances where the intubation tube has of 
necessity been allowed to remain too long a time in the larynx. 
The ulcerative process, after removal of the tube, may form 
not only cicatricial bands, but there may be also increased fibrous 
tissue in the submucosa. I have seen a number of cases in which 
tracheotomy had been performed, and, owing to the lesion of the 
larynx, the tracheotomy-tube had to be worn for several months. 
In these cases the larynx was completely occluded later by newly- 
formed fibrous tissue. Such a condition is well illustrated in a 
case (Fig. 225) treated by Dr. Chevalier Jackson, of Pittsburg. 

The symptoms consist in a permanent hoarseness of the 
voice or restriction in its register. There may be some interfer- 
ence with breathing, dependent in amount upon the degree of 
stenosis. Intermittent attacks of dyspnea continuing for many 
years are always pathognomonic of syphilitic lesion of the larynx 
(Lennox Browne). The cough is spasmodic, the expectoration 
scanty. Pain and difficulty in swallowing are usually marked, 
although they may be absent. The bizarre formation of the laryn- 
geal enmeshment will aid in the diagnosis. 



<®><g)<g)<8) 



Fig. 225.— Drawn from a case of postdiphtheritic subglottic stenosis cured by galvano- 
cauterization of the hypertrophies by the direct method : A, Immediately after removal 
of the intubation-tube. Hypertrophies like turbinals are seen projecting into the lumen 
below the cords ; B, five minutes later. The masses have now closed the lumen almost 
completely. The patient became so cyanotic a bronchoscope was at once introduced to 
prevent asphyxia; C, the left mass has been cauterized by a vertical application of the 
incandescent galvanocautery knife ; D, completely and permanently cured after repeated 
cauterizations. 



MALFORMATIONS AND DEFORMITIES. 631 

Treatment.— Treatment should consist in a prompt meeting 
of alarming or aggravating symptoms. Tracheotomy may be 
required when edema occurs, and should always be done as low 
down as possible. The tube should under no consideration be 
allowed to be removed, lest subsequent edema should prevent re! 
insertion. Intubation alone is not generally successful. Dilatation 
ol the structures by means of the instrument shown in Fig 2^6 
after cutting ,s extremely slow and uncertain. The wearing of 
O Dwyer's tubes after this operation, or the passage of E Is 
the most rapid and satisfactory method oougies, is 

Tuberculous Stenosis is rarely ever cicatricial, as the tu- 
bercular process does not tend to heal. The only danger is 
from the edema. The healing in lupus, however, wKrm 

Sding CICatn0ial bandS ' the SCar - tISSUe bein S -V A™ »d 

trizS U o S f 7; i T1 l 1 1 , ' r0Wing °, the lar - Vn « eal a P ert « re > d «e to cica- 
ZTZf ♦ , ln PUfu>volvement, is characterized by a gen- 
era matting together of the parts, which may be to the extent 
of he formation of a pin-hole aperture. The tissues are gener- 
ally anemic, except where small rosy nodules give evidence of 
acute inflammation. The symptoms "are out of proportion to the 
actual appearance j difficulty in swallowing and Ca lib g are 
usually absent, and there is not often great modificatio f the 
voice. _ The situation of the lupous web is generally ™ktc 
evd of tS' P i,,° r tHberC " l0sis 1 , t l 1 e structures below Ld°at he 
level oi th.s aperture are generally attacked. Lupus of the face 




Fig. 226,-Mackenzie's laryngeal dilator. 

exami^tiom " 3 " 7 diagn0Sticated ma >' be ^nfirmed by laryngeal 
The prognosis is generally not so grave as for the other con 

S.rr^f , the de ?° sit ^nndergo a spontTonsZ 
gradual atrophy, which may be complicated By a later change of 
condition to actual true tuberculosis. 8 

ThItlV' e t y /^ e nanwi ?g sh °»W determine the treatment. 
The dense, elastic character of the scar-tissue renders intubation 
of little permanent value, and simple dilatation is ineffectual 
unless coupled with cutting or slitting of the web 



632 DISEASES OF THE LARYNX. 

Operation within the larynx in the nature of cutting or incising 
the tissue should not be undertaken until all signs of inflamma- 
tion have disappeared, and in no case unless there is an absolute 
demand for operative interference. 

Narrowing of the larynx by leprosy occurs late in the disease, 
and need only be considered to suggest the necessity of tracheot- 
omy to prevent asphyxia. 

INFLAMMATORY DISEASES OF THE LARYNX. 
COUGH. 

One of the most troublesome and frequent conditions from 
which the patient seeks relief is cough. In itself it is a reflex 
movement. Primarily, there must be some irritation of the 
sensory fibers of the pneumogastric nerves. The impulse created 
by this irritation, being transmitted to the ganglia, is referred 
back to the trachea, bronchial tubes and lungs through the = 
motor filaments of the same nerve. This produces the spasmodic, 
complex phenomena of expulsive contraction ordinarily known as 
cough. In itself it is merely a symptom, but in cause and effect 
it is most varied and far-reaching, and while the condition is 
treated under many different heads and chapters, it is of sufficient 
importance to necessitate a separate consideration. 

Cough may be due to local causes, or it may be merely a local 
manifestation of a systemic condition. It may be reflex or 
direct ; mechanical or sympathetic ; voluntary or reflex ; it may be 
due to irritation of the pharyngeal mucous membrane, brought 
about by involvement of the follicles of the pharynx — the so- 
called follicular pharyngitis. The same thing is true of lateral 
glandular pharyngitis. 

Age is also an etiological factor in causing cough. In the 
very young the glandular structures about the neck are more 
likely to become involved, and, through swelling and pressure, 
may produce, either reflexly or directly, sufficient irritation to 
produce cough. 

Mechanical irritation of the nasal mucous membrane in some 
individuals will produce cough. Irregularities in the nasal or 
nasopharyngeal cavities, may be an exciting factor. 

Enlarged tonsils and elongated uvula may also excite cough, 
especially when the person is lying down. During meal-time, or 
when swallowing fluids, relief from such a cough will be obtained. 

Chondritis and perichondritis, in fact, any inflammatory lesion 
of the larynx, either acute or chronic, and especially when asso- 
ciated with any of the specific granulomata, such as syphilis and 
tuberculosis, are exciting factors of cough. 

In some individuals hardened wax in the ear, by reflex irrita- 
tion through the filaments of the auditory nerve, may cause cough, 
I have seen a number of such cases. 



COUGH. 633 

Enlarged bronchial glands following infections of the larynx, 
tonsils, bronchial tubes, and after pneumonia, owing to an involve- 
ment of the nerve-filaments by pressure, may keep up a prolonged 
hacking cough. 

Foreign bodies imbedded in the tracheal or bronchial mucous 
membrane, or anywhere in the upper respiratory tract, are mechan- 
ical exciting factors of cough. 

Broncoliths, although of rare occurrence, will keep up a con- 
tinuous spasmodic cough until the offending body, which acts 
the same as a foreign body, is expelled. I have observed one 
case in my private practice in which there was a small saccular 
dilatation in the bronchial tube, and in which had formed a bron- 
colith, which w T as expelled in a violent fit of coughing. In a 
short time, and under sedative remedies, the patient made an unin- 
terrupted recovery. 

The dry, hacking cough ; the deep, resonant cough ; the spas- 
modic, barking cough ; the paroxysmal cough ; the hysterical 
cough ; the brassy cough ; the laryngeal cough ; the croupy 
cough ; the loose, rattling cough, and the character of the secre- 
tion expectorated, are all significant and to the observing physician 
are valuable aids in diagnosis. 

Frequently associated with neurotic lesions and lesions of the 
cord, such as locomotor ataxia, there is a peculiar, spasmodic, dry, 
rasping cough. 

Allied conditions, where there is profuse secretion, will bring 
about cough. There is always associated with asthmatic condi- 
tions, regardless of cause, a certain amount of cough. Choreic 
children are especially susceptible to cough. Boys at the age of 
puberty frequently show T a certain amount of congested laryngeal 
mucous membrane and not infrequently have a peculiar nervous, 
hacking cough. 

Xasal growths and foreign bodies are also exciting factors. The 
same is true of hypertrophy of the turbinate bodies, hyperplasias 
and edemas of any of the upper respiratory mucous membrane. 

Trauma of the nose, especially where the bones are broken, has 
been frequently noted as an exciting factor, and, even besides pro- 
ducing violent coughing, has produced congestion of the bronchial 
and pulmonary membrane. The so-called " night-cough " may be 
due to mechanical conditions, or may be brought about by obstruc- 
tion to nasal-breathing and enforced mouth-breathing. 

Laryngeal tumors ; paralysis of the vocal cords, complete or 
partial ; specific inflammatory lesions, either with new formation or 
ulceration, are frequently the exciting factors in producing cough. 

That cough may be due to pressure from an aneurysm is also a 
well-known fact. 

In angioneurotic edema in which the bronchial mucosa is in- 
volved, the patient has prolonged and irritating cough. 



634 DISEASES OF THE LARYNX. 

The renal and uterine reflex coughs are frequently seen, but 
very difficult to explain ; however, the fact exists that lesions 
of these parts will undoubtedly produce cough. 

The so-called cough spots mentioned by Stoerck are nothing 
more than localized inflammatory areas or blocked--up glands of 
the mucous membrane, and the small, inflamed area acts as an 
exciting factor. 

The terms ear cough, laryngeal cough, bronchial cough, pleu- 
ritic cough, hepatic cough, asthmatic cough, cough of fatigue, 
adenoid cough, nasal cough, cardiac cough, nervous cough (see 
p. 759), and stomach cough, are all insignificant, each one in turn 
suggesting and implying a definite cause and each involving an 
entirely different line of treatment. 

ACUTE CATARRHAL LARYNGITIS. 

Synonyms. — Acute catarrh of the larynx; Laryngorrhea ; 
Spurious croup. 

Definition. — An acute catarrhal inflammation of the mucous 
membrane of the larynx, giving rise to slight dyspnea and hoarse- 
ness, which is seldom dangerous to life, although more severe 
when occurring in children. The inflammation may be either 
superficial, identical with parenchymatous involvement in other 
organs, or interstitial, involving deeper structure, with a greater 
likelihood to become chronic and leave permanent alteration. 

Etiology. — The causes of acute catarrhal inflammation of the 
larynx are such as favor similar affections of mucous membranes 
generally, though it is to be noted that of the entire respiratory 
tract, lesions of the larynx are less common than of any other 
portion. Individuals, especially children, who are kept indoors a 
greater portion of the time, are especially liable to the disease. 
Those in whom the general health is poor on account of some 
constitutional diathesis are usually sensitive, owing to the lowered 
resistance of the membrane. Irregularities of the gastro-intestinal 
tract emphasize the susceptibility. This is more marked in children. 
Cold and exposure, particularly by allowing the feet to> remain 
wet or cold or by wearing damp clothing, predispose to the condi- 
tion, unless the body is kept active. Obstructive lesions of the 
nose by which mouth-breathing is demanded are directly or indi- 
rectly exciting factors, just as the direct inhalation of improperly 
moistened air or particles of dust sets up irritation and renders one 
susceptible. Continued and excessive use of the voice and strain- 
ing of the parts by violent coughing are not uncommon causes. 
The overuse of hot or alcoholic drinks and the constant or pro- 
longed use of tobacco, either by chewing or smoking, by reason of 
their local and systemic stimulating effect, are also exciting factors. 
Moreover, improperly ventilated rooms predispose. Irritating 
fumes from stoves or from the register, by being inhaled or from 



ACUTE CATARRHAL LARYNGITIS. 635 

the patient sleeping in the direct line of the current of heat, will 
frequently bring on an acute attack of laryngitis. Irritating 
vapors from gas-tanks or a leaking gas-jet are equally exciting. 
Dusty air, chemical vapors, as mentioned in the occupation variety 
of laryngitis, are important factors. The inflammatory condition 
frequently extends to the trachea and bronchial tubes. Continued 
outdoor habits rarely ever predispose to the disease, as private and 
hospital records show that the majority of cases occur in indi- 
viduals of indoor or sedentary habits. Previous attacks are main- 
tained by some as predisposing to others ; but, if the case is care- 
fully investigated, it will be found that this tendency to recur- 
rence is due rather to the individual being exposed to a con- 
dition similar to, or his systemic condition being the same as, 
that which brought on the previous attack. Age and sex are not 
important etiological factors, the environments of the individual, 
his habits of life, and his general condition playing by far the most 
important part. The laryngeal catarrh may be merely an accom- 
paniment of the eruptive fevers, influenza, or hay-fever, or may 
occur along with an asthmatic tendency. Foreign bodies lodged 
about the larynx may also bring about laryngeal inflammation. 
The same is true of external pressure from any cause. Frequently 
attacks of acute laryngitis may be set up by the application of 
remedial agents to the pharynx. Several such cases have come 
under my notice, in which the powders or fluids applied directly to 
the pharynx were inspired by the patient, bringing about a severe 
and acute attack of laryngitis. 

Pathology. — The pathology of acute catarrhal inflammation 
of the larynx is identical with that occurring in any portion of the 
mucous membrane in the upper respiratory tract, with the excep- 
tion that in the larynx the glandular element is quite deficient and 
the excessive catarrhal exudate is rather the product of inflam- 
mation, while in the other mucous-membrane tracts the excessive 
exudate is the result of hypersecretion plus the inflammatory exu- 
date. There is a vascular engorgement which, owing to the struct- 
ure of the larynx, would be bound to lessen its lumen and produce 
slight impairment of breathing, and in the first stage of the inflam- 
matory process the membrane would be dry, producing a sensation 
of raspiness and discomfort. This is followed by hypersecretion 
and exudation by reason of leakage from the engorged vessels and 
the overflow of mucus from the pent-up gland-secretion. Owing 
to the desquamation of the epithelial cells and leukocytes the exu- 
date becomes more tenacious and white in color. Unless the 
irritation be kept up, with the relief of the engorgement and the 
restoration of the circulation to normal the symptoms rapidly dis- 
appear, and there is left no structural alteration. However, in 
many cases the exciting or predisposing cause is continued, and 



636 DISEASES OF THE LARYNX. 

the condition passes into a chronic inflammation, with permanent 
structural alteration. 

Symptoms. — Frequently the first symptom noticed will be a 
disposition to cough, owing to slight dryness of the throat, and a 
sudden alteration in the voice, which will be rapidly followed by 
considerable soreness or a sensation of roughness and thickening in 
the throat, with a feeling of constriction. To the sense of touch 
there is practically no pain, but attempts to use the voice cause 
aggravation of all the symptoms above mentioned. Often the 
voice may remain hoarse throughout the entire attack, but fre- 
quently there is sudden loss of voice, in which the patient is unable 
to speak above a whisper. The cough is usually shrill and metallic, 
and in the early stages is dry and rasping. Impeded respiration 
is more marked in children, although, unless attended by consider- 
able edema, as seen in the traumatic variety, the interference is not 
marked. As the case progresses into the second stage, the secretion 
will considerably relieve the dryness and cough, which will become 
less rasping and irritating. There may be a slight rise of tem- 
perature, especially in children. In either the second or third 
stage of the disease in young subjects, suffocative attacks may 
occur during sleep. This is most likely due to accumulated or 
dried secretions within the larynx. Examination of the laryngeal 
mucous membranes shows a distinct hyperemia of the entire sur- 
face. The injected vessels may be distinctly outlined. Occasion- 
ally, minute ruptures may occur, allowing leakage into the sub- 
mucosa. This hemorrhagic condition may occur as the result of 
violent respiratory efforts, as in coughing or vomiting, and has 
given rise to the variety known as hemorrhagic laryngitis. The 
mucous membrane will appear swollen and tense, and occasionally 
the injection of the ventricular bands will cause them to overlap 
the true cords slightly, and thus interfere with phonation. The 
epiglottis may be slightly engorged, but, as a rule, there is no 
tendency to edema. Occasionally, small areas may be covered 
with tenacious secretion, causing slight desquamation of epi- 
thelial cells underneath, and on inspection somewhat resembles 
areas of ulceration. The interference with phonation may be the 
result of involvement of the base of the vocal cords, but is oftener 
due to involvement of the surrounding structures, such as the 
ventricular bands, the epiglottis, rim of the glottis, or the mem- 
brane covering the arytenoids. The interference with innervation 
in the inflammatory stage is a secondary matter ; the irregular and 
incomplete tension of the cord is brought about rather by the 
congestion of the vessels and the inflammatory exudate into 
the submucosa. 

Diagnosis. — The objective and subjective symptoms are quite 
clear. However, in children and young adults the possibility of 



ACUTE CATARRHAL LARYNGITIS. 637 

their being symptoms of a more serious lesion, such as diphtheria 
or the eruptive fevers, should always be taken into eonsideration. 

Prognosis. — The prognosis is favorable. Many cases will 
recover in a few days with very little if any treatment, although 
in some instances in which the exciting factor persists the condi- 
tion passes into one of chronic inflammation. 

Treatment. — An acute inflammatory process involving the 
mucous membrane of the larynx is not always a serious condition, 
yet, from its location and the tendency to edema, with subsequent 
interference to respiration, it always demands prompt and energetic 
treatment. By the use of the laryngoscope the area of inflamma- 
tion can be outlined and its severity determined. If seen early 
and the process is limited, with no threatened edema, such reme- 
dial agents should be used as will relax peripheral vessels, thereby 
diminishing local pressure. For this purpose, as well as to lessen 
the dry, irritating cough, there should be administered internally 
every hour, for three or four doses, an effervescing pilocarpin 
tablet containing y^-Q grain of the drug. Hot mustard foot-baths 
should be given, followed by hot drinks, such as hot lemonade, to 
promote diaphoresis. The temperature of the room, maintained 
at from 60° to 70° F., should be rendered soothing to the inflamed 
membrane by surcharging the air with steam. Attention should 
be given to the condition of the intestinal tract, and, although 
there is no existing constipation, a gentle purgative is beneficial 
from its general derivative action. No irritating food of any kind 
should be allowed during the course of the disease. This plan of 
treatment in a majority of cases will relieve the congestion and 
rapidly promote resolution. If the tissue surrounding the cords 
be involved in the inflammatory process, inhalation of compound 
tincture of benzoin, a teaspoonful to a half-pint of boiling water, 
is useful. If there is marked irritation, there may be added to 
the benzo'in a teaspoonful of paregoric. Equally good is the local 
application, by means of spray or nebulizer, of some bland oil, such 
as liquid vaselin or albolene 1 ounce, to which is added from 4 to 
6 drops of oil of sandal-wood and 1 to 3 drops of oil of tar. If 
the inflammatory process be in the early stage, and the patient's 
occupation demands the constant use of the voice, relief can be 
given in a few hours by the administration of 5 to 10 drops of 
dilute nitric acid in water, repeated at first every half-hour, then 
every hour, for two or three doses, or a tablet of — 

1^. Acidi nitrici diluti, miij (.18) ; 

Tincturse opii deodorati, Tftiij (.18) ; 

Cocain phenate, gr. yL- (.006) ; 

given every hour for three or four doses, will often give prompt 
relief, from its action on the arterioles and relief of the conges- 



638 DISEASES OF THE LARYNX. 

tion, thereby depleting the part. If this treatment is used in 
the evening, the morning will usually show a return of the con- 
dition, unless the irritation be very much localized, when there 
is more hope of a permanent recovery. 

The use of external applications affords some relief. In the 
early inflammatory process the external application of cold by 
means of the ordinary ice- or cold-water bag may prove beneficial. 
This should be used only early in the case, and should not be 
applied longer than a few minutes at a time, repeated application 
for a short period affording more relief than the continued appli- 
cation. The insufflation of powders is highly objectionable, as the 
irritation produced by such agents increases the condition that is 
sought to be relieved. It must be remembered that diseases of the 
larynx are not cured by gargles ; that the cases in which the vari- 
ous solutions used as gargles seem to be beneficial are those in 
which there is associated pharyngeal involvement or inflammation 
of the lingual tonsil. In the stage of exudation, when there is 
profuse secretion, before applying the oily solution as recom- 
mended above, the parts may be sprayed by a simple cleansing 
alkaline wash, such as biborate or bicarbonate of sodium, 10 to 15 
grains to the ounce of tepid water. Very little of such applica- 
tion will come in contact with the laryngeal tissue, but it serves to 
clean away the mucus surrounding the epiglottis and low down in 
the pharynx. 

When there is existing edema involving the glottis and laryn- 
geal structure, prompt surgical interference is necessary. The 
edematous tissue must be punctured. Puncturing is better than 
scarifying, as there is less danger of causing any serious hemor- 
rhage, and there is less laceration of tissue. It must be remem- 
bered that in edema the engorgement is not a vascular one, but 
a watery infiltration of the perivascular structure, and that such 
exudation somewhat relieves the engorged vessels. Puncturing, 
then, will relieve this watery infiltration, while scarifying will 
accomplish the same end, but with the added evil of more exten- 
sive laceration, with hemorrhage. This procedure may be followed 
by the application of mild astringents, such as liquor ferri persul- 
phatis, 5 to 10 drops to the ounce, argenti nitras, 2 to 5 grains to 
the ounce. 

If the edema be rapid and well advanced and the danger of 
suffocation imminent, immediate intubation or tracheotomy is 
indicated. 

If there is a tendency, after the subsidence of the acute attack, 
to huskiness or even complete loss of the voice, lasting for several 
days or weeks, there should be administered internally 5-grain 
doses of benzoate of sodium, or dram doses of compound elixir of 
terpin hydrate (Llewellyn's). At the same time there should be 



ACUTE LARYNGITIS IN CONSTITUTIONAL DISEASES. 639 

used locally mild astringents, such as tannin or alum, 5 to 10 
grains to the ounce of water, in spray. 

General medication is not usually indicated in acute laryngitis, 
although there may be attendant conditions demanding special 
attention. For the distressing cough there maybe administered 
an anodyne, as codein sulphate in doses of gr. -^ to \, repeated 
only to the point of relief of the symptom. It must be remem- 
bered that many cases of apparent laryngeal cough are due to 
mechanical irritants, and that if the coughing is continued a suffi- 
cient length of time and is paroxysmal in character, the act itself 
may bring about laryngeal congestion and simulate true disease of 
the larynx ; in such conditions sedatives are indicated. In indi- 
viduals of a rheumatic or gouty tendency an alkali should be given. 
The importance of resting the voice during any laryngeal involve- 
ment cannot be overestimated ; and if the vocal bands are mark- 
edly involved in the inflammatory process, causing complete loss 
of voice, absolute rest should be insisted upon. 



ACUTE LARYNGITIS IN CONSTITUTIONAL DISEASES. 

Erysipelas. — The larynx may be involved primarily by ery- 
sipelas, or the disease may extend from its cutaneous site to im- 
plication of that organ. 

Many of the so-called idiopathic cases of facial erysipelas may 
be explained by a pre-existing faucial involvement. The inten- 
sity of the erysipelatous involvement may range from a simple 
diffused redness with edema, through a phlyctenular type, in which 
vesicles or blebs are found resembling herpes, which, when rupt- 
ured, discharge serum or pus, and have a yellowish-white, easily 
detachable base, to gangrenous changes of the structures. The 
disease is generally epidemic or endemic ; it may begin with a 
chill, followed by fever, vomiting, delirium, and prostration, with 
local throat-symptoms of pain, dyspnea, or odynophagia. The lar- 
ynx early in the affection resembles an acute attack of simple lar- 
yngitis, but the tendency of the affection to extend, the occurrence 
of other cases, the constitutional involvement, lymphatic enlarge- 
ment, together with the bacteriological finding, early distinguish it 
from the simpler form. 

The prognosis should be grave and guarded, as the great 
majority of cases prove fatal. 

The treatment should be that applied to erysipelas in general, 
plus the relieving of symptoms caused by its special involvement. 
Tincture of chlorid of iron, quinin and whiskey or brandy should 
be given frequently in large doses. 

Some authors have strongly recommended the local application 
of nitrate of silver, 60 grains to the ounce, at the junction of the 
diseased with the healthy membrane. Antiseptic mouth-washes 



640 DISEASES OF THE LARYNX. 

and gargles should be employed. Cocain or menthol, 10 per cent. 
in albolene, sprayed over the tissue affected, will relieve the pain. 
Counterirritants externally are of doubtful value. 

Measles. — One of the constant and characteristic symptoms of 
measles is a catarrhal inflammation of the entire upper respiratory 
tract, either preceded or accompanied by the characteristic spot- 
ting of the disease. This catarrhal condition may exist through- 
out the attack, and leave the membrane in a condition favorable to 
subsequent involvement. In the great majority of cases the laryn- 
geal implication rarely exceeds a catarrhal type, though occasionally 
mechanical ulceration from coughing, or even gangrene, may be 
met with. The inflammatory condition may assume a pseudo- 
membranous form. In severe cases of the laryngitis of measles 
the symptoms consist of a dry, hard, painfully frequent cough, a 
loud, whistling respiration, and, rarely, suffocative spasmodic 
attacks, followed by the expectoration of dry, inspissated mucus. 
The larynx, on inspection, is of a deep-red color, the vocal cords 
yellowish-red and slightly injected. 

The prognosis for measles is not rendered more grave by the 
ordinary catarrhal involvement, except by the danger of sudden 
edema ; but in the other varieties, such as the membranous or 
ulcerative, the outlook is exceedingly serious as regards recovery. 

The treatment should consist in the rigorous use of antiseptic 
and detergent sprays or gargles, as prophylactic measures, before 
there is any actual involvement of the larynx. Boric acid, 10 
grains to the ounce, or aqueous extract of hamamelis, hydrogen 
peroxid, and cinnamon water, in equal parts, may be used for this 
purpose. If there is much pain, a gargle of — 

1^. Chloral hydrate, gr. x (.6) ; 

Glycerini, 3ss (3.9) ; 

Aquae, fl^j (30.) 

should be employed as often as necessary. The ulcerative and 
gangrenous lesions may receive similar treatment, plus the ap- 
plication of the compound tincture of benzoin and 50 per cent, 
boroglycerid equal parts to the former and 10 per cent, alumnol 
to the latter. 

Scarlet Fever. — The laryngeal involvement of scarlet fever 
is usually mild, consisting in a hyperemia or slight catarrhal 
inflammation. This is proved by the fact that hoarseness and 
cough are not usually met with in scarlatina. In severe and 
grave cases, however, the laryngeal involvement may be the 
main source of danger. There may be in instances of this kind 
a severe catarrhal laryngitis with edema ; ulceration may occur, 
pseudomembrane may form, or even gangrene result. 

Small-pox. — In small-pox the larynx is frequently involved. 



ACUTE LARYNGITIS IN CONSTITUTIONAL DISEASES. 641 

There may be only a catarrhal involvement, as evidenced by hoarse- 
ness, or edema of the aryepiglottic folds may occur, as may ulcera- 
tion of a degree even to perforation ; cord paralysis, spasm, and even 
mechanical obstruction due to redundant tissue may occur. In the 
confluent or hemorrhagic forms of variola the laryngeal legions are 
proportionately graver, and asphyxia may result from the swelling, 
collection of viscid phlegm, and spasm of the glottis. Permanent 
alteration or loss of voice may result from the ulcerative laryngeal 
involvement. Pseudomembranes may form in the larynx during 
the course of the disease, or true diphtheria may complicate it. 

Typhoid Fever. — During the course of typhoid fever the 
larynx in a certain percentage of cases may be involved by a 
simple catarrhal inflammatory process, or, by extension from the 
pharynx, may be implicated in any of the processes mentioned as 
occurring in that locality. Ulceration of the larynx occurs in a 
few cases, and may consist in a simple catarrhal ulceration — ulcer- 
ative lesions closely akin to those found in the intestine, or of a 
diphtheritic character. These lesions do not usually develop until 
late in the disease, and may even destroy the cartilages in their 
necrotic involvement. They are considered under Chondritis and 
Perichondritis. This process may give rise to alarming edema. 

Typhus Fever. — Laryngitis is at times met with in typhus 
fever, and is usually a dangerous complication. The swollen mem- 
brane assumes a bright- or dusky-red, hue covered with sticky 
mucus or pus. Occasionally, ulceration of a peculiarly destructive 
type is observed, often baring the cartilages and leaving a blackish- 
gray denuded surface. 

Influenza. — In a considerable proportion of cases of influ- 
enza the larynx is involved in an acute inflammatory process, 
evidenced by aphonia of an intermittent character. The mucous 
membrane is swollen, shiny, and reddened ; later, white or grayish 
spots may appear, resembling superficial necrosis. Edema, local- 
ized or general, may supervene at any time, requiring prompt and 
energetic interference. Spasm or paralysis may result, or an in- 
flamed condition left that may persist indefinitely, resulting in a 
chronic inflammation. 

Miasmatic Epiglottitis.— Under this heading Jacob D. 
Arnold in Burnett's System mentions an acute inflammatory condi- 
tion particularly involving the epiglottis. There is marked edema 
of that structure, causing dyspnea and odynophagia, and in one 
case reported by him the obstruction to breathing became so great 
that tracheotomy was performed. He believed the condition " due 
to some animal, vegetable, or chemical poison in the exhalations 
of the salt marshes." 

Malarial poisoning may evidence itself locally in the larynx by 
producing symptoms resembling croup. Fever occurring at regu- 

41 



642 DISEASES OF THE LARYNX. 

lar intervals, as well as hoarseness, difficult breathing, and injec- 
tion of the structure, are the main symptoms. 

The enlarged epiglottis should be punctured or scarified, with 
the patient's head held forward to prevent entrance of the contents 
into the larynx. Ice-water sprays and astringents will hasten reso- 
lution. If malaria be the suspected cause, quinin in the form of 
the bromid should be administered. 

Rheumatism. — Acute involvement of the larynx by rheuma- 
tism has been observed in a number of cases. It may consist in a 
rheumatic arthritis, evidenced by pain on attempted phonation and 
by hyperemia of varying amount ; the cords may be immobile, 
swollen, and deeply colored, while the articulation affected is 
swollen and tender. The gums and teeth should be examined for 
evidence of uric-acid diathesis. 

Sedative applications internally and counterirritation by a 
blister externally, in conjunction with the administration of the 
salicylates and tonics, may be efficient aids in relieving the con- 
dition. 

PURPURA HEMORRHAGICA. 

Purpura hemorrhagica may involve the laryngeal mucous 
membrane and produce a condition quite similar to edema of the 
larynx. The thickened mucous membrane may block sufficiently 
the laryngeal space so as to interfere with breathing. The disease 
is usually more marked in the vestibule of the larynx, although 
the entire structure may be involved. 

The symptoms, cough, difficulty in respiration, and so on, are 
practically the same as in any other edematous condition of the 
larynx. Cases of purpura hemorrhagica of the larynx have 
been reported as following vaccination and the injection of anti- 
toxin. However, the condition may have been an associated one 
rather than a result. 

ACUTE LARYNGITIS IN CHILDREN. 

Synonyms. — Spasmodic croup ; False croup. 

The acute catarrhal inflammation involving the mucous mem- 
brane of the larynx in children does not differ in its etiology and 
pathology from the same condition occurring in adults ; but the 
fact that the caliber of the larynx is much smaller in children, 
the mucous-membrane structure more relaxed, with a tendency to 
rapid engorgement, makes the condition more serious, and alters 
the symptoms and course of the disease. The inflammation may 
involve the membrane above the glottis, and is known as acute 
supraglottic laryngitis; or it may be limited to the membrane 
below the glottis, and is called subglottic laryngitis ; or both struct- 
ures may be involved under the general term of acute laryngitis, 
in which there would be combined the symptoms of both supra- 
and subglottic inflammation. In children the condition is most 



ACUTE LARYNGITIS IN CHILDREN. 643 

likely to occur between the ages of two and five years, although 
it may occur as early as the first or as late as the fifteenth year. 
The condition may be brought about by any mild catarrhal inflam- 
mation of the upper air-passages, or as a result of inflammation of 
the pharyngeal, faucial, or lingual tonsil. I think in children quite 
frequently the predisposing cause will be found in involvement of 
the lingual tonsil, due to its close proximity to the larynx and 
epiglottis and its direct lymphatic and blood-supply. The usual 
exciting cause is exposure to cold, possibly increased by some sys- 
temic irregularities, such as gastric or gastro-intestinal lesions. 
There may be associated some systemic disturbance, such as fever, 
with loss of appetite, or there may be entire absence of gastric 
symptoms, the inflammation being purely local and involving the 
supraglottic structure. There will be hoarseness of voice, and in 
some cases complete aphonia. There is usually a sensation of 
irritation in the throat, although seldom sufficient to cause pro- 
nounced coughing. If the inflammation is limited to the supra- 
glottic region, there will be very little dyspnea, with little or no 
tendency to spasm of the glottis. It is a much milder form than 
the subglottic variety, in which there is more likely to be spasm 
of the glottis. Any acute inflammatory condition involving the 
laryngeal membrane in children should always be looked upon 
with suspicion, and the diagnosis determined as rapidly as possible. 
In children it is difficult to make a complete laryngoscopic exam- 
ination, although with care and patience in the majority of cases a 
good view of the larynx can be obtained. I do not agree with 
some writers that forcible examination should be made and the 
child's tongue held until it struggles or gags, as I think the irrita- 
tion produced is of decided harm to the child ; but, on the con- 
trary, there should be as little irritation aud muscular spasm as pos- 
sible. In itself the supraglottic variety is not dangerous, but the 
inflammatory process tends to become subglottic. This is espe- 
cially true if it is associated with inflammatory processes in adjacent 
structures, such as the tonsils, either pharyngeal, faucial or lingual. 
It must be remembered that this variety of acute laryngitis is also 
an early symptom of much graver lesions — those in scarlet fever 
and diphtheria. The mucous membrane, not only of the laryngeal 
structure but of the entire respiratory tract, may present a condi- 
tion of catarrhal inflammation. 

Treatment. — The treatment of acute laryngitis in children 
should be begun by the administration of divided doses of calomel 
and bicarbonate of soda, followed by a saline. The air of the room 
in which the patient is confined should be kept moist and soothing 
bv generating steam in a kettle or other appliance. Applications 
direct to the larynx are not only difficult but exceedingly danger- 
ous, and should not be resorted to. Inflammatory involvement 
of adjacent structures, such as the pharynx, nasopharynx, or ton- 



644 DISEASES OF THE LARYNX. 

sils, should receive prompt and energetic attention, if the laryn- 
geal implication is to be bettered. Externally, camphorated oil 
should be energetically rubbed into the tissues about the larynx 
and overlying the trachea and bronchi. Early in the attack benefit 
may result from wrapping about the throat a towel, the end of which, 
next the skin, should be dipped in ice water from time to time. 
Coal oil diluted may be applied on flannel to the neck as a coun- 
terirritant, and allowed to remain in position over night. For the 
profuse secretion compound tincture of camphor combined with 
squills, given in dram doses, answers admirably. Dover's powder 
in small doses serves, as does paregoric, to allay the irritating 
cough. Internally, good results can be obtained by giving repeat- 
edly hot milk seasoned with salt as strongly as can be taken. 
Should the symptoms demand an emetic, the administration of 
a teaspoonful of sodium chlorid, followed by warm water, will act 
promptly. 

In the way of prophylaxis much can be done with those chil- 
dren predisposed, by inherited tubercular or other tendency, to 
frequent laryngeal and pulmonary attacks. Cold sponge-baths 
combined with brisk friction, flannels of proper weight worn 
throughout the year, a suitable chest-protector, outdoor life, prop- 
erly ventilated rooms (especially the bed-chamber), an annual 
excursion to the sea or mountains for salt or pure air, are to be 
insisted upon whenever practicable or possible. 

LARYNGISMUS STRIDULUS. 

Synonyms. — Spasm of the glottis ; Spasmus glottidis ; Spasm 
of the larynx ; Laryngeal spasm ; Spasmodic laryngitis ; Spasm of 
the abductors of the vocal cords ; Spasmodic croup ; Cerebral 
croup ; False croup ; Child-crowing ; Thymic asthma ; Miller's 
asthma ; Asthma rachiticum. 

Laryngismus stridulus denotes spasm of the larynx accompanied 
by stridor, and while in itself it is not a separate disease, yet it is 
an alarming symptom, which may be associated with any affection 
of the larynx or trachea, due either to direct lesion or indirectly 
from reflex causes of irritation. It is most common in children. 
It may be a symptom in inflammatory or uninflammatory diseases 
of the larynx. For example, spasm of the larynx with stridor is 
observed in croup (either true or false), whooping cough, gastric or 
intestinal disturbances — such as intestinal catarrh, constipation, or 
intestinal worms— and during dentition ; it may occur along with 
other convulsive symptoms ; it may be present in rachitic children 
or children of the neurotic temperament ; it may be brought about 
by direct irritation of the fauces by foreign material, or new 
growths, or by the application of drugs ; it may be reflex from 
irritation in the nasopharynx ; it may also be reflexly associated 



LARYNGISMUS STRIDULUS. 645 

with uterine lesions or sexual excesses. Again, it may be due to 
uric-acid diathesis, as observed by Cohen in a case in which laryn- 
gismus stridulus was cured by relieving the uric-acid tendency. 
Moreover, the spasm may be caused by an elongated uvula drop- 
ping into and irritating the laryngeal structure. It may also 
occur in laryngeal crises of tabes, and would be associated with 
absent knee-jerk and ataxia. Caries of the vertebrae may also, 
from pressure, bring about spasm of the larynx. The same is true 
from pressure of enlarged thymus gland (thymic asthma) (see p. 210), 
acute or chronic abscess, as well as from enlarged bronchial glands. 
This may be either direct or from pressure on some part of the pneu- 
mogastric or spinal accessory nerve. There may be also associated 
some paralysis of the posterior crico-arytenoid muscle, either 
bilateral or unilateral. Lesions of the tongue, especially enlarge- 
ment of the lingual tonsil, are important direct or reflex etiological 
factors. The spasm may also be a symptom where cerebral irritation 
exists. The condition should be looked upon and treated as an 
associated lesion, or rather a local manifestation dependent upon 
some local, constitutional, or remote disease, which is reflected 
from the muscles of the larynx, and is in reality a neurosis. It is 
a symptom and not a disease. 

The conditions in which laryngismus stridulus is best illus- 
trated are spasm of the larynx in children, spasm of the larynx in 
adults, and spasmodic laryngitis. 

Treatment. — Quite frequently the spasm will relax before 
death occurs, owing to the anesthetic effect produced by the 
retained carbonic-acid gas, due to interference with respiration ; 
however, this cannot always be depended upon, and the condition 
is so alarming as to call for immediate relief, and may demand 
the performance of tracheotomy at once. Direct inspection of the 
pharynx and larynx should be made without delay to determine 
the presence of foreign bodies or any source of irritation. Between 
the attacks careful search should be instituted for the direct or 
reflex cause, as the relief of the condition in the majority of cases 
will be determined by the controlling of the associated or reflex 
lesions. For the relief of the paroxysm the dashing of cold water 
on the face or neck, or the application of hot water to the nape of 
the neck, will often give prompt relief. Traction on the tongue by 
firmly grasping the tongue between the thumb and index finger 
and making traction at intervals of eighteen times per minute, by 
reason of its reflex action, is one of the simplest and best methods 
to relieve the patient of the spasm. Should the jaws be set, 
almost the same reflex action can be produced by placing the 
fingers under the angle of the jaw and making traction by deep- 
seated pressure. 



646 DISEASES OF THE LARYNX. 

Congenital Stridor. 

This curious phenomenon involves the laryngeal and tracheal 
structures. Various explanations and theories have been offered 
to account for the clinical phenomena observed in this condition. 
It is likely that a number of conditions are responsible rather 
than any one. Such etiological factors as reflex laryngeal irri- 
tation produced by the presence of adenoid structure in the naso- 
pharynx ; congenital malformation of the upper portion of the 
larynx ; pressure on the trachea from an enlarged sinus gland ; 
and spasmodic action of the respiratory muscles, causing deformity 
of the larynx, have all been advanced. The author observed one 
case in which he believed it to be entirely due to deformity of 
the cartilages of the larynx, where, from displacement, there 
probably was some slight nerve involvement which brought about 
the spasmodic muscular action associated with the stridor. 

Symptoms. — The symptoms come on early in life. It has 
been noticed shortly after birth. The breathing is noisy, consist- 
ing of a croaking sound accompanying inspiration. The more 
forcible the inspiration, the higher the pitch. In expiration the 
croaking noise is of shorter duration. Occasionally the breathing 
assumes the normal, and there is no evidence whatever of any 
stridor, only to return again without any exciting factor. The 
stridor goes on whether the child is asleep or awake. Excite- 
ment, emotional or physical, or the act of crying, will intensify 
or increase the stridor. The power of crying and coughing on 
the part of the child is not at all affected. Curiously enough, 
while the breathing is noisy, yet the passage of air does not seem 
to be obstructed, there being apparently no narrowing of the 
lumen of the larynx. There is not the slightest sign of distress 
on the part of the child, neither is there any cyanosis. There 
may be, however, marked inspiratory indrawing of the thoracic 
and abdominal walls, especially in severe cases. The stridor 
may increase during the first few months, then remain stationary 
for an indefinite time, and gradually lessen and finally disappear. 
It usually lasts from a few months to the second year. 

Spasm of the Larynx in Children. 

Synonym. — Spasm of the glottis in children. 

Etiology. — Given a rachitic child fed on improper food, with 
unhygienic environment, insufficiently clad, let some intercurrent 
provocation, such as a prolonged fit of crying, exposure to cold, 
fright, irritation of the gums in dentition, intestinal worms, for- 
eign bodies in the esophagus, acute indigestion, whooping cough, 
or the entrance of a drop of milk into the larynx be interposed, 
and you have all the conditions favorable for an attack of spasm 
of the larynx. Enlarged bronchial or tracheal glands, by pressure 
on the laryngeal nerves, may also give rise to the condition. 



LARYNGISMUS STRIDULUS. 647 

Pathology. — Impairment of nutrition at the nerve-centers 
controlling the larynx renders them unstable, and impulses, either 
originating there, or referred from a larynx locally disturbed, or 
coming from other portions of the body, are reflected to the larynx, 
causing spasmodic closure of the glottis by stimulating the action 
of the tensors and adductors of the vocal cords. 

Symptoms. — The child, usually less than two years of age, 
is suddenly seized, either waking from sleep or while awake, 
with an attack of dyspnea, drawing the air in with the greatest 
difficulty and forcing it out after equally great effort ; or, starting 
up in bed from a sound sleep, with an expression of terror in its 
face, respiration may be for ten to twenty seconds absolutely 
impossible ; the child becomes cyanotic, the neck becomes turgid, 
the eyes converge, spasmodic contractions of the hands or feet may 
occur, or there may be a general convulsive seizure even to opis- 
thotonos, which may terminate fatally, rarely, in the first attack ; 
or, the spasm of the larynx relaxing, the symptoms abate, and with 
a loud inspiration the child lies completely exhausted. A series of 
these seizures may take place, separated by minutes, hours, or 
days, and even weeks may elapse before a recurrence. The nutri- 
tion of the child, originally bad, is rendered worse by the loss of 
sleep and the drain on the nervous system. 

Diagnosis. — A neoplasm may cause dyspnea that is pro- 
gressive, in contradistinction to the suddenness of its onset in 
this affection ; hoarseness or loss of voice is usually noticed in 
intralaryngeal growths. Fever and symptoms pointing toward 
laryngeal involvement between the attacks indicate laryngitis, 
edema, or general infectious disease. Bilateral abductor paralysis 
is rare in infancy, is more chronic in character, and the attacks of 
dyspnea, though longer, are not so severe. 

Prognosis. — The extent of impairment of the general health 
and the severity and frequency of recurrence control the outlook, 
which is at best exceedingly grave. 

Treatment. — The treatment of a case of spasm of the larynx 
comprises the controlling of the spasm and attempts to prevent its 
recurrence. 

During the actual attack the clothing of the child should be 
loosened, and the windows of the room opened to allow the en- 
trance of fresh air. Place the child in a semi-recumbent position, 
with the feet in a mustard foot-bath at 95° F. Apply mustard 
plasters to the back of the neck. Dash cold water in the face or 
apply cold compresses to the head. A y 1 ^- grain of morphin, with 
3" or g ram of atropin subcutaneously, Bos worth considers safe. 
Ammonia, chloroform, or nitrate of amyl by inhalation might be 
attempted, though the interference with respiration would seem to 
render these agents useless. Tickling the back of the throat with 
a feather may cause vomiting and relieve the spasm. Traction on 
the tongue may be resorted to, as described under Laryngismus 



648 DISEASES OF THE LARYNX. 

Stridulus. Oxygen under pressure is beneficial. Should the 
spasm threaten life, intubation, the introduction of a soft catheter 
into the larynx, or tracheotomy should be done at once. 

During the intervals between the attack the direct and indirect 
causes should be diligently sought for and corrected. The general 
condition should be built up by the administration of cod-liver 
oil, hypophosphites, or syrup of iodid of iron. The food should 
be nutritious and non-irritating ; the clothing should be warm and 
protective. The child should be placed in healthy surroundings 
and out of doors as much as possible. Lance the gums if the 
teeth be at fault. If the child nurses with difficulty from the 
breast, feed with a spoon. To prevent recurrences by quieting 
the nerve-centers and conduits, use chloral, bromid of soda, anti- 
pyrin, physostigmin, or valerian. 

Spasm of the Larynx in Adults. 

Synonym. — Spasm of the glottis in adults. 

Etiology. — An abnormal excitability of the nervous system 
predisposes to attacks of spasm of the larynx in the adult. The 
direct course of the condition is generally reflex in nature, orig- 
inating, as a rule, from some diseased condition in the respiratory 
tract, though stimulus may come from other sources. Again, it 
may be but one of the symptoms of a systemic disease. The so- 
called laryngeal crisis occurring in locomotor ataxia may be cited 
as illustrative of the last variety of causes, as may diphtheria, 
hydrophobia, and tetanus. Such conditions as atrophic or hyper- 
plastic rhinitis, nasal polyps, adenoids, deflected septum, and 
obstructive lesion of the upper air-tract may reflexly produce the 
condition ; the same is true of lesions of the ear. Syphilis, tuber- 
culosis, traumatism, ulcers, tumors, rough instrumentation or ex- 
amination, or foreign bodies in the larynx or adjacent structures 
may reflexly cause the spasmodic laryngeal closure. Central 
nerve-lesion or pressure on the efferent nerve by a bronchocele, 
aneurysm, enlarged glands, tumors, or any enlargement may also 
produce a similar result. The spasm may also be due to or asso- 
ciated with tubercular laryngitis. The condition is often noted in 
hysterical individuals. One such case I observed in my own 
practice, in which spasm of a most alarming nature occurred. 

Symptoms. — The attack of dyspnea, varying in degree and 
frequency according to the cause, usually lasting but for a few 
seconds, comes on generally at night. There is a struggle for 
breath, a few crowing, noisy respirations with cyanosis. The 
attack gradually subsides, the spasm lasting from five to twenty 
seconds. There are lacking the periodicity and regularity in the 
recurrence of seizures seen in glottic spasm in children. Attacks 
during the day are more apt to be due to central nerve-lesion, 
pressure on the nerve-trunk, or systemic affection, such as loco- 



LARYNGISMUS STRIDULUS. 649 

motor ataxia, in which case there is likely to be a precedent 
cough. 

Diagnosis. — The main difficulty in the diagnosis of the con- 
dition is the accurate establishment of the underlying cause. Care- 
fully examine the upper air-passages for abnormality of disease. 
Look for the other symptoms of the general involvement, if tabes 
or other systemic disease be the cause. The laryngeal image, by 
revealing the impaired movement of the muscles supplied, will 
aid in establishing a pressure-lesion on one of the nerves. In 
bilateral abductor paralysis the laryngeal image will show an 
absence of abducting motion, making clear the diagnosis. 

Prognosis. — Except in those cases due to systemic involve- 
ment the outlook for relief of the condition is usually good, fatal 
termination of a spasm being fortunately a rare occurrence. 

Treatment. — Removal of spurs from the septum, correction 
of deflections, ablation of polyps or adenoids, treatment of the atro- 
phic or hyperplastic conditions, in fact, the correction or removal 
of any diseased condition of the upper respiratory tract, is essen- 
tial to cure. Frequently the spasm can be controlled by the 
application of bland oils to the nasopharynx. To alleviate the 
attack or correct the nervous instability and hypersensitiveness, 
bromid of potassium or sodium should be given in 10- to 15-grain 
doses three or four times a day, increasing the daily doses by 5 
grains until a result is obtained. The personal hygiene of the 
patient should be looked to, and a nutritious diet and outdoor 
exercise insisted upon. Should the condition be due to nerve- 
pressure, the excitable and irritable laryngeal mucosa, as in all 
other conditions, should be soothed by spraying a 2 per cent, 
cocain or menthol solution, or by the inhalation of such antispas- 
modics or sedatives as infusion of poppies, or tincture of benzoin 
with paregoric. 

Spasmodic Laryngitis. 

Synonyms. — Stridulous laryngitis ; Stridulous angina ; Laryn- 
gitis stridulosa ; Spasmodic croup ; Mucous croup ; Spurious croup ; 
False croup ; Catarrhal croup ; Catarrhal laryngitis ; Spasm of the 
larynx ; Pseudocroup. 

Spasmodic laryngitis is a condition in w T hich there is always 
present an inflammation of the laryngeal and tracheal mucous 
membrane, associated with spasmodic contraction of the muscles 
of the larynx, which gives rise to peculiar cough, difficult respira- 
tion, stridor, and even paroxysms of dyspnea. The inflammatory 
process may be very slight, yet the spasm be quite marked. It 
may be supraglottic or subglottic, the supraglottic variety being 
usually associated with spasm, while the subglottic variety is true 
or membranous croup, although in many cases an involvement of 
both supra- and sub-glottic structures occurs. There is a condi- 



650 DISEASES OF THE LARYNX. 

tion of spasm of the glottis, or true laryngismus stridulus, which 
is purely a neurotic condition and not connected with any inflam- 
matory process ; it is spasmodic, begins suddenly, and abates rap- 
idly. It is identical with the tonic convulsion of external muscles, 
being limited in this case to the internal muscles of respiration. 

Etiology.— Of the predisposing causes of spasmodic laryngitis 
or false croup, inherited tendency plays an important part, chil- 
dren of lymphatic temperament being especially liable. Children 
with short, stout, chubby necks are also predisposed. Intestinal 
irregularities and gastric disorders in children are also predispos- 
ing factors. The exciting factor in most cases is exposure to 
cold. The condition is not uncommon in the commencement 
of various childhood diseases, especially in measles. In child- 
hood the narrowness of the rima glottidis, coupled with the sus- 
ceptibility of the nervous system, forms an additional predis- 
posing factor. 

Pathology. — As to the pathological alteration little is known. 
In the few cases in which post-mortem reports have been given, 
little or no alteration in the laryngeal structure was noted, outside 
of some tumefaction of the tissue, which in a number of cases was 
more than likely due to the use of remedial agents rather than the 
result of the disease-process. It would seem that the etiological 
factor was remote from the site of the disease, and that the spasm 
of the laryngeal muscles was due to direct or indirect nerve-irrita- 
tion rather than a local inflammatory process, and the condition 
should properly be classed under Neuroses. There is, however, 
nearly always some local inflammatory process, and it is difficult 
to determine whether this be the cause of the laryngeal spasm or 
merely an allied condition. 

Symptoms. — The disease is strictly one of childhood, and 
occurs in children from a few months to ten or twelve years of 
age. The spasmodic seizures are usually preceded by slight cough 
and the characteristic symptoms of a mild coryza. However, in 
some cases the onset is abrupt, and the premonitory symptoms are 
absent. One of the peculiarities of the condition is that it occurs 
at night — usually after the first sleep — between ten and twelve 
o'clock. The child may go to sleep quietly and naturally, and in 
a few hours awake with a loud, rasping, wheezing, asthmatic cough, 
struggles and gasps for breath, and the breathing has a peculiar 
whistling sound on inspiration. The face is flushed and anxious, 
with a marked expression of terror, and the child will cling to the 
attendant as though frightened. The pulse is hard and full, owing 
to the increase of vascular tension by improper respiratory func- 
tion. The attack may last from a half-hour to two or three hours. 
Usually, with proper treatment, in a half-hour the symptoms have 
abated, and the child drops off into a sleep indicative of fatigue. 
Occasionally the attack may be repeated the same night, or during 
subsequent nights. The inflammatory action is more marked after 



LARYNGISMUS STRIDULUS. 651 

the abatement of the attack than before ; however, this can be 
explained by the irritation produced by the violent coughing and 
labored breathing. Frequently for two or three days the child 
has a hoarse, croupy cough, with profuse catarrhal secretion ; and, 
where the cold and exposure have been pronounced, the attack 
may be followed by catarrhal pneumonia. 

Diagnosis. — The condition may be — in fact, quite frequently 
is — mistaken for pseudomembranous croup. However, the true 
membranous variety begins insidiously, with slight cough, which 
gradually increases in intensity. The cough becomes more harsh 
and the respiration more difficult by degrees, and continues by 
day as well as by night ; while the spasmodic laryngitis or false 
croup commences abruptly, may be preceded by slight cough and 
nasal catarrh, yet the onset, in which respiration is interfered with, 
is sudden, and rapidly reaches its maximum intensity. It always 
occurs at night. In true croup the cough is harsh and rough from 
the presence of the membrane, portions of which may be coughed 
up ; in spasmodic laryngitis the cough is loud, wheezy, and dry, 
and the alteration in the voice is due only to the interference with 
respiration ; in the membranous variety the voice is altered, due 
to the presence of foreign material. In true croup the alteration 
in voice is gradual, while in spasmodic laryngitis it is sudden. 
Besides, in the membranous variety careful inspection will usually 
show on the faucial surface evidence of false membrane ; while in 
the spasmodic variety the membrane is not present, with usually 
very little, if any, inflammation in the faucial structure. 

Prognosis. — Under proper treatment the prognosis is favor- 
able, although the fact must not be overlooked that death may 
occur. The symptoms of unfavorable termination are the con- 
tinued marked dyspnea, which does not respond to proper remedial 
agents ; stridulous breathing, both inspiratory and expiratory ; the 
lividity of the face and the fingers, due to cyanotic congestion, on 
account of the lack of oxidation and non-aeration of the blood ; 
cold, pallid surface and irregular pulse, with tendency to con- 
vulsions. 

Treatment. — The treatment should be directed, first, to 
relieving the spasmodic action of the laryngeal muscles, and, 
secondly, to allaying any laryngeal inflammation. For the first 
there is nothing better than the warm bath, which should be at a 
temperature as warm as can be comfortably borne. The little 
patient should be left in the bath at least ten or fifteen minutes, 
and placed so as to be completely immersed, with the exception of 
the head, allowing the water to extend up to the chin. Sufficient 
ground mustard may be added to the bath to promote surface 
stimulation. With the warm bath should be combined the use of 
emetics. For very young children the syrup of ipecacuanha in 
doses of 20 to 60 drops, repeated every twenty to thirty minutes 
until vomiting occurs, is one of the best emetics. For children 



652 DISEASES OF THE LARYNX. 

over three years of age there may be combined with the syrup of 
ipecacuanha an equal amount of syrup of squill. Warm salt water 
will also produce the same effect, or if immediate vomiting is 
necessary, irritation of the fauces by the tip of the finger, or run- 
ning the finger down the throat, may produce a sufficient reflex to 
induce vomiting. The object of the warm bath and the emetic is 
to promote relaxation and stimulate secretion. A few whiffs of 
ether or chloroform will produce relaxation in the cases in which 
there is associated very little inflammatory process. To prevent 
the recurrence of the attack, careful attention should be given to 
the study of the condition of the bowels, and if the movements are 
not free and brisk a purgative should be administered, followed by 
a saline cathartic. Of the purgatives there is none better than 
calomel, in doses graduated to the age of the child, followed by a 
decided dose of Rochelle or Epsom salts. If an emetic has been 
administered, it will be necessary to wait some little time before 
the administration of any other medicine, on account of the nausea 
produced by the emetic. In the spasmodic variety of laryngitis 
inhalations are of some slight benefit ; but, owing to the interference 
with respiration, scarcely enough of the medicated vapor reaches 
the area to produce any marked benefit. The application of 
mustard plasters to the neck and sternum, or, in the very young, 
the hot spice poultice to the chest, is highly beneficial. Inhalations 
of slacked lime do very little good, but tend to moisten the atmo- 
sphere of the room. If there is much laryngitis following the 
attack, stimulating expectorants, such as ammonium carbonate, 
should be administered after careful attention has been given to the 
intestinal tract. In the majority of cases subject to such attacks 
the child is of a nervous temperament, and general treatment should 
be directed toward the improvement of the general system. There 
should be administered chalybeate and vegetable tonics, and plenty 
of outdoor exercise is indicated. The victim of such attacks should 
never be kept in a room in which the air is likely to become dry, nor 
placed where there will be a direct current of air from a heater or 
gas from a stove. After an attack beneficial results can be obtained 
for the prevention of a recurrence on the following night by coating 
the neck over the region of the irritation with crude petroleum, 
late in the afternoon or early in the evening. A flannel cloth, 
saturated with the crude oil and left in contact with the tissue for 
two or three hours, will do much toward stimulating secretion and 
circulation. 

ACUTE EPIGLOTTITIS. 

This term has been applied to conditions in which acute inflam- 
mation is largely limited to the epiglottis. It is not, in reality, a 
separate condition, as there is always an associated laryngitis, with 
pharyngitis or inflammation of the lingual or faucial tonsil. In many 
cases it is entirely due to involvement of the lingual tonsil. There 



TRAUMATIC LARYNGITIS. 



653 



is frequently, however, an involvement of the pharynx and epiglot- 
tis, with only slight, if any, laryngeal implication. In such cases 
there are no symptoms referable to the larynx, though attempt at 
swallowing may cause some laryngeal spasm. The patient com- 
plains of the sensation of a foreign body in the throat, an inclina- 
tion to gag or vomit, slight difficulty in swallow- 
ing, with very little, if any, pain. There is marked 
tendency to edema. There is an excessive secre- 
tion of mucus, which is more marked after meals 
or when the tissue has been irritated. As a rule, 
there is no tenderness on pressure, although at 
times there may be slight tenderness over the 
hyoid bone. There are no constitutional symp- 
toms unless the condition is associated with graver 
lesions elsewhere. 

The treatment is practically the same as for 
acute laryngitis. Should there be any tendency 
to edema, it may be necessary to puncture or 
scarify the tissue, as directed under Edematous 
Laryngitis. The instrument shown in Fig. 227 
is useful for puncturing the edematous tissue. 

TRAUMATIC LARYNGITIS. 

This variety of inflammation differs very little 
from acute laryngitis, except as to cause and sever- 
ity, the severity depending entirely upon the nature 
of the injury. It is a violent inflammatory process 
of the mucous membrane, not only of the larynx, 
but usually of adjacent structures and of the con- 
tiguous mucous membranes. When due to foreign 
bodies or direct wounds the inflammation may be 
limited to the laryngeal structure. From inha- 
lation of vapors, from scalds or burns, or from 
corrosive poisons, the inflammatory process not 
only involves the larynx, but also the structures 
above — the fauces, tongue, and especially the ton- 
sils. The last-named variety is most likely to oc- 
cur in quite young children. From scalds, burns, 
or corrosive poisons the inflammation is generally 
very violent in character, and nearly always fol- 
lowed by gangrene. Usually there is marked 
edema at the same time ; in fact, the condition is almost the same as 
edematous laryngitis, though differing in degree. The inflammation 
set up by a foreign body generally subsides on the removal of the 
offending substance ; however, the wound may be sufficient to cause 
alarming edema and wide diffusion of the inflammatory process, and 
even after the removal of the foreign body, owing to the respira- 



Fig. 227.— Brun's 
epiglottis pincet. 



654 DISEASES OF THE LARYNX. 

tory interference, tracheotomy may be imperative. The edematous 
condition present should be treated in the same way as edematous 
laryngitis ; while in the cases in Avhich the process is brought 
about by corrosive poisons, scalds, or burns, emollient applications 
are most suitable, such as sweet oil with menthol, gr. iv to the 
ounce, or camphorated oil and vaselin in equal parts, with boric 
acid, gr. v, and menthol, gr. iv, to the ounce. 

For the relief of the edema, puncture or scarification is the 
most rational method of treatment. The interference with res- 
piration should be carefully watched, and if there is alarming 
dyspnea, with danger of immediate suffocation, prompt tracheot- 
omy should be performed. Non-depressant emetics may be of 
some value ; but, as a rule, the process is very rapid, and much 
of the edema and swelling occurs almost instantly (from the 
above-mentioned causes) ; for in reality the edema and leakage 
from the blood-vessels at the start do not constitute an inflamma- 
tory process, but are more in the nature of a blister, and may be 
followed by inflammation. 

SUPPURATIVE LARYNGITIS. 

Synonyms. — Phlegmonous laryngitis; Purulent laryngitis; 
Suppuration of the larynx. 

Suppurative processes involving the larynx should really not 
be called suppurative laryngitis, for the inflammatory process 
involving the laryngeal mucous membrane is secondary to some 
infectious condition in the submucosa or the cartilaginous or bony 
framework of the larynx. The majority of the cases originate in a 
chondritis or perichondritis, most commonly due to syphilitic lesion 
or following typhoid fever. In many cases the latter cause is 
overlooked, as is shown by Keen in his work on Surgical Compli- 
cations of Typhoid Fever. The threatening complication of any 
suppurative process involving the larynx is edema, due to the 
infiltration from the surrounding inflammatory area, so that the 
symptoms produced by laryngeal suppuration are almost identical 
with acute edema. The upper part of the larynx is most fre- 
quently involved, although the suppurative process, originally 
supraglottic, may by extension of the inflammatory process rapidly 
involve the cords and become subglottic. 

Pathology. — The pathology is that of abscess-formation, and 
does not differ from that occurring elsewhere. When the lesion 
is due to an inflammation of the cartilage, where necrosis of that 
structure takes place, there is likely to be breaking down of the 
tissue, with discharge of necrotic cartilage or bone. The condition 
may be a localization of some septic infection. 

Symptoms. — There is a localized spot of tenderness exter- 
nally, and there may be some external swelling. The pain is con- 
tinuous, although not excessive, but is increased on pressure. 



RHEUMATIC LARYNGITIS. 655 

Deglutition is difficult, with irregular impairment of the voice and 
respiration. The interference in respiration and oxidation of the 
blood is manifested by the red face and tendency to cyanosis, 
which comes and goes with the increase in, or relief from, the 
swelling. There is a constant tendency to clear the throat. The 
patient will have acute attacks of choking, which will be relieved 
after a violent fit of coughing. The inflammation about the 
aryteno-epiglottic folds and about the cords and epiglottis below 
is so great as to render it impossible to inspect the larynx. 

Diagnosis. — The localized point of tenderness externally, the 
history of the case, the systemic symptoms, the rather slow prog- 
ress of the affection, will aid in differentiating the condition from 
diphtheria and membranous or spasmodic croup. 

Prognosis. — The prognosis is generally bad, the patient dying 
from suffocation or general systemic infection. 

Treatment. — Early in the lesion cold should be applied 
externally, and the patient allowed to keep small pieces of ice in 
the mouth. The air in the room should be kept moist, and the 
patient's general condition supported by stimulants. The edema- 
tous structure should be scarified, and as soon as the threatened 
area of suppuration can be localized, it should be frequently scari- 
fied. If there is evidence of chondritis or perichondritis, an in- 
cision should he made over the localized spot of tenderness. 
However, before resorting to such surgical procedure, trache- 
otomy should be performed. As a rule, intubation is of no avail, 
as the edema and inflammatory swelling extend below the point 
reached by the tube. 

RHEUMATIC LARYNGITIS. 

Synonyms. — Laryngeal rheumatism ; Gouty sore throat ; 
Gouty throat ; Lithemic laryngitis. 

Acute laryngitis that is due to a rheumatic or gouty diathesis 
differs only from the simple acute laryngitis in that the cause is an 
irritating material within the circulation, locally manifested by 
disturbance in the laryngeal mucous membrane. There is more 
pain than in the simple variety, with greater tendency to throat- 
ache. There may be no other signs of rheumatism ; indeed, the 
urinary examination may show deficient elimination instead of 
excess ; this, however, is more highly important than an excess, 
as it shows a retention of the products of urea within the circula- 
tion. The pain may be increased on deglutition and external 
pressure. Occasionally in the severe types there may be slight 
laryngeal hemorrhage, owing to the rupture of the congested 
vessels ; as a rule, however, there is an associated inflammation 
of the larynx and tonsils, although it may be limited to the laryn- 
geal structure. There is usually marked alteration of the voice, 



656 DISEASES OF THE LARYNX. 

with hoarseness, and even aphonia. One of the main symptoms, 
outside of the local laryngeal manifestations, is the lassitude, even 
hebetude, of which the patient complains. Additional symptoms 
are the inability to think and work, with draggy feeling and slight, 
aching pains in the muscles of the neck. The patient frequently 
complains on swallowing of a peculiar " creaky " sensation in the 
throat, and at times there is almost a distinct click. There is a 
constant tendency to clear the throat, although no pronounced 
cough. In the true gouty conditions there may be a deposit about 
the crico-arytenoid joints ; but, as a rule, in this variety there are 
systemic manifestations of the conditions, yet the throat-manifesta- 
tions are always pronounced and the symptoms intensified. 

Treatment. — The treatment is practically the same as that 
indicated in gout or rheumatic conditions when occurring in other 
portions of the upper respiratory tract, and should consist in the 
internal medication, as local treatment is only palliative, and is 
practically the same as given under Rheumatic Pharyngitis. 

EDEMATOUS LARYNGITIS. 

Synonyms. — Purulent or suppurative laryngitis ; Phlegmon- 
ous laryngitis ; Edema glottidis ; Acute cellulitis of the larynx ; 
Edema of the glottis. 

This is a condition of the laryngeal mucous membrane in which 
there is watery infiltration into the submucosa, owing to leakage 
from vessels, either from sudden hyperemia or from the hyperemia 
and congestion of inflammations, or in cyanotic conditions (angio- 
neurotic). 

Although there are a number of varieties of edema given by 
the various writers, they are all really based on the exciting cause, 
and the edematous process is practically one and the same. If the 
process is infectious, it may run a more rapid course, yet there 
is not sufficient difference to warrant the confusion caused by a 
description of the varieties based on cause. 

Etiology. — The condition may be brought about first by 
injuries in which there are fractures producing sudden inflamma- 
tory processes, or by inhalations of steam, irritating vapors, or 
escharotics. It may also be caused by the accidental swallowing 
of irritating fluids, or even by the careless application of medicinal 
agents. This occurred in a case brought to my notice, in which 
the edema was alarming, and was brought about by the patient 
making a sudden inspiratory effort after the application of a solid 
stick of nitrate of silver to an ulcer of the tonsil, by which the 
secretion was drawn into the larynx. Again, the edema may be 
due to inflammatory conditions in adjacent structures, such as 
abscess in the tonsil or peritonsillar tissues ; enlarged and sup- 
purating lymphatic glands of the neck, causing pressure ; wounds 



EDEMATOUS LARYNGITIS. 657 

or foreign bodies at the base of the tongue, involving the lingual 
tonsil ; tumors involving adjacent structures, by their pressure 
and interference with venous return. Foreign bodies in the 
esophagus, located directly behind the laryngeal or tracheal struct- 
ure, may also cause the condition, as may chondritis or perichon- 
dritis. This affection is frequently associated with specific inflam- 
matory processes, or, as is shown by Keen in his work on Surgical 
Complications of Typhoid Fever, is often the result of that disease. 
Under the classification of primary and secondary edema can be 
included all the causes. The edema, however, in the majority of 
cases is secondary. Quite frequently the edema is brought about, 
although more of a chronic variety, by cardiac lesions, in which 
there is lessened vascular tone, with a tendency to cyanotic condi- 
tions of the lax structures, in which the blood is dammed back on 
the venous circulation. There will be produced in the mucous 
membrane of the upper respiratory tract a condition analogous to 
that occurring in the kidney and liver, known as cyanotic con- 
gestion. Owing to the lax structure, there is a tendency to watery 
infiltration, and the so-called chronic edema results. Again, in fibroid 
changes in such structures as the liver, kidney, and lung, in which 
there is interference with the systemic circulation, the blood is 
dammed back on the venous system, and a cyanotic condition 
is produced in the membrane, identical Avith that of the cardiac 
lesion. In the specific inflammations due to local ulceration, with 
subsequent fibroid-tissue formation and contraction, there may 
be involvement of the venous structures to such an extent as to 
produce local edema. Major surgical operations about the throat 
and lower jaw, in which considerable scar-tissue formation has 
taken place through the fibroid contraction, may produce the same 
condition. Infectious processes of the surface, such as occur in 
diphtheria, scarlet fever, and streptococcal infection, all of which 
are likely to be quite virulent, may rapidly bring on an acute 
edema. This may be due to the direct infection or to spreading 
of the inflammatory process by continuity or contiguity of struct- 
ure. The acute edema is usually attended by acute inflammation, 
while the chronic edema may have no local inflammatory process 
as an exciting factor. As a rule, it is dependent upon some struct- 
ural alteration which involves venous circulation, either in direct 
relation with the part or from organic lesions. In acute thyroid- 
itis there is always alarming edema of the glottis, as well as involve- 
ment of the deeper pharyngeal structures, and also cellulitis of the 
neck (see p. 558) ; in this condition the cellular infiltration may 
become so marked as to give every evidence of pus-formation, 
even to fluctuation. The leukocyte count in inflammation involv- 
ing the thyroid gland is also very high. In one case observed by 
the author the leukocyte count ran 80,000 and the clinical 
symptoms pointed to pus-formation involving the deep cervical 

42 



658 DISEASES OF THE LARYNX. 

structures, and extending in so as to bulge over the epiglottis, and 
to all appearances had gone on to abscess formation. It was 
only the knowledge that in acute thyroiditis this leukocyte count 
was so increased that prevented surgical interference. The case 
made an uninterrupted recovery without surgical interference when 
the treatment was directed toward the acute thyroiditis. 

Pathology. — The high vascularity of the larynx, together 
with the fact that the blood-vessels of the mucous membrane are 
practically unsupported, permits rapid congestion, and there is a 
leakage into the perivascular tissue. This exuded serum fills the 
intercellular spaces and lymph-channels, and a certain amount is 
taken up by the connective tissue or epithelium. This in turn 
may, if not promptly relieved, give rise to hydropic degeneration 
— especially true in the chronic form, although it is rare in the 
acute form, as in acute edema the case terminates before such 
degenerative change can take place. Besides, the watery infiltra- 
tion exerts a certain amount of pressure, and thereby lessens cel- 
lular nutrition, which in chronic edema would tend to further 
degenerative changes. That in the acute varieties there is very 
little structural alteration is shown by the fact that when the case 
goes on to actual recovery there is practically no structural altera- 
tion, the tissue returning to its normal function. The edema may 
be more marked in the ventricular bands, the epiglottis, or the 
aryepiglottic folds. The surrounding laryngeal structure may also 
be involved, and it may even extend to the muscles of the neck. 
In some cases the edematous condition exists not only in the 
larynx but in the trachea. This is especially true when the excit- 
ing cause is the inhalation of irritating materials, such as flame, 
steam, escharotics, or foreign bodies. In chronic edema, while 
the alteration is not so marked, it may involve the same structures. 
Post-mortem examination will show very little edematous infiltra- 
tion, but the relaxed structure can be seen ; this condition, as far 
as is demonstrated after death, is practically the same as in hyper- 
emia or congestion — simply showing the result, and not the actual 
process itself. 

Symptoms. — In acute edema the onset is sudden, and if con- 
current with inflammation of adjacent structures, there may be 
chilly sensations or an actual chill. There is rapid and early im- 
pairment of the voice in addition to stridulous breathing. Dysp- 
nea is one of the early symptoms. The interference in breathing, 
both inspiratory and expiratory, becomes rapidly more marked, 
and the face becomes flushed ; in fact, the whole systemic circula- 
tion shows the interference with the respiratory function, combined 
with the lessened oxidation of the blood and the elimination of 
poisonous gases. The patient is restless and apprehensive. The 
symptoms rapidly increasing, some few cases demand prompt sur- 
gical interference, or they will terminate in death. Fortunately, 



EDEMATOUS LARYNGITIS. 659 

in almost all instances the attack is not so severe nor the symp- 
toms so marked. There is considerable pain on swallowing, 
and a sensation in the throat as of a foreign body. There is a 
wheezy, labored cough, with unsuccessful effort to clear the throat, 
the expectoration being very slight. The patient is more comfort- 
able in the upright position, with the body leaning slightly for- 
ward. Inspection will show the epiglottis enormously swollen — 
in fact, so much so, in many cases, as to obstruct the laryngeal 
view — and frequently the edematous condition will have so altered 
the anatomical relations as to render laryngeal examination of 
little value. Rapid digital examination, together with the unmis- 
takable symptoms of laryngeal obstruction, is sufficient to deter- 
mine the diagnosis. AVhile the edematous condition may be sub- 
glottic, as a rule it involves not only the entire intralaryngeal 
structure, but also the surrounding tissues. In the chronic variety 
the symptoms are not so alarming ; the onset is slower, the altera- 
tion in the voice is more gradual, and the interference with respira- 
tion less marked and irregular. The condition may last for weeks 
without serious complication, and through the collateral circula- 
tion the tendency to cyanotic congestion may be relieved. If it is 
due to cicatricial contraction or local involvement, such as is 
observed in tumors, such alarming symptoms may be produced as 
to necessitate tracheotomy. 

The diagnosis in acute edema can be easily made by inspection 
and by subjective symptoms. In chronic edema, by the history of 
the case, with a careful laryngeal examination, the diagnosis can 
be established. 

Prognosis. — In the acute variety the prognosis is favorable 
if prompt treatment is instituted. However, the symptoms may 
be so alarming as to make tracheotomy imperative. Where the 
involvement of the structure is extensive and is below the point 
that can be relieved by tracheotomy, the prognosis is bad. 

Treatment. — The treatment should first be directed toward 
relief of the edema, whether it be due to an acute phlegmonous 
inflammation, passive congestion, irritation from foreign bodies, or 
irritating vapors, and then the curative or the prophylactic treat- 
ment should be addressed to the underlying cause. 

Besides the irritation caused by disease-processes in the struct- 
ures immediately adjacent, it must be remembered that edema of 
the larynx may be caused by cardiac and pulmonary conditions 
producing cyanosis of the mucous membrane ; furthermore, renal 
and hepatic lesions, especially the fibrous changes, through their 
action on the heart, may bring about the same condition. In all 
such cases the constitutional treatment should be directed toward 
the offending structure, to prevent, if possible, a recurrent attack. 

For immediate relief of the edema, puncturing or scarifying 
should be done at once ; the patient should be given a saline 



660 DISEASES OF THE LARYNX. 

cathartic and kept in a warm room, in an atmosphere thoroughly 
surcharged with moisture, and a diaphoretic administered. The 
punctures and scarifying should be done according to the rules 
mentioned under Acute Laryngitis with subsequent edema. The 
application of astringents after puncturing is rarely necessary if 
the above method has been carried out. However, should it be 
necessary to apply astringents, 10 grains to the ounce of nitrate 
of silver, or a 10 per cent, alumnol solution, should be used. As 
a rule, if the puncturing be followed by the application of a 20 to 
30 per cent, aqueous solution of ichthyol, the tendency to recur- 
rence is markedly diminished, as the ichthyol promotes rapid reso- 
lution. In all cases of edema concurrent with renal, cardiac, or 
hepatic disorders, free daily movements of the bowels must be 
secured until the condition is relieved. The external application 
of cold, in the form of the ice-bag or Leiter's coils, or the applica- 
tion of leeches may be of service in arresting further edema, as the 
effect produced by such procedure is largely limited to the blood- 
vessel itself, while the condition to be relieved is entirely a peri- 
vascular one, and consists of a watery infiltration of the structures 
involved. Such procedure, then, would be of service only by 
toning up the vessel-walls, and in this way preventing further 
leakage, but would not affect the serum already poured into the 
perivascular tissue. 

In cases of sudden edema which commonly are attended by 
acute suppurative processes, it may be so sudden and rapid that 
the patient is in danger of suffocation. In these instances intuba- 
tion or tracheotomy should be performed at once. Tracheotomy 
is preferable to laryngotomy only because the opening in the air- 
passages is at a point away from the inflammatory process. In 
edema of the larynx associated with syphilitic lesions, it must be 
remembered that the administration of potassium iodid, while not 
actually producing the condition, tends to complicate and aggra- 
vate it, and should be discontinued. 

Edema may occur along with either perichondritis or chon- 
dritis as a causative factor, and when the diagnosis is assured, the 
treatment should consist, early in the condition, in the applica- 
tion of the aqueous solution of ichthyol internally, and exter- 
nally an ointment of ichthyol and lanolin, in equal parts. Should 
the edema be threatening and require immediate relief, it will be 
necessary to resort to scarification and puncture. Involvement of 
the cartilage or pericartilaginous structures is seldom concurrent 
with simple acute inflammatory processes, but commonly with 
infectious diseases, especially typhoid fever. 

Adrenalin chlorid, owing to its contracting powers, is a very 
beneficial agent when locally applied to edema of the glottis, 
epiglottis, and laryngeal structures. However, the old physio- 
logical law that to every action there must be a reaction, espe- 



MEMBRANOUS LARYNGITIS. 661 

cially holds true in the action of this drug, and sometimes its 
action is followed by such a severe reaction that the edema comes 
on with greater severity. 

CHRONIC EDEMA OF THE LARYNX. 

This condition is generally due either to some local manifes- 
tation of a systemic condition, such as syphilis, tuberculosis, or 
malignant growths, or is brought about by systemic alterations. 
It may be the sequel of acute edema. The pathological alteration 
in the structure is one of hydropic degeneration and pressure- 
atrophy. 

The prognosis is bad as to cure, and the treatment con- 
sists in scarification (page 659), if due to tuberculosis, or syphilis, 
or systemic conditions such as cyanotic lesions ; if due to malig- 
nant growths, tracheotomy is usually imperative. 

MEMBRANOUS LARYNGITIS. 

Synonyms. — True croup ; Membranous croup ; Diphtheritic 
croup; Idiopathic membranous croup ; Pseudomembranous croup; 
Fibrinous croup; Pseudomembranous laryngitis; Fibrinous laryn- 
gitis ; Croupous laryngitis ; Laryngeal diphtheria ; Laryngotra- 
cheitis ; Cynanchea trachealis. 

Varieties of membranous laryngitis correspond with mem- 
branous varieties of inflammation of the mucous membrane as 
given under Pharynx and Nose, — namely, croupous, fibrinoplastic, 
and diphtheritic. The. following description pertains more to the 
croupous and fibrinoplastic, the diphtheritic being fully con- 
sidered under Diphtheria. 

This affection consists in a membranous inflammation involv- 
ing the laryngeal mucous membrane, especially the subglottic por- 
tion, in which there is poured out on the surface a croupous or 
membranous exudate, which is highly fibrinous, coagulable, and 
albuminoid. That bacteriological research in many of these cases 
shows the presence of the Klebs-Loffler bacillus, either in its 
virulent or modified form, does not alter the clinical fact that 
frequently such inflammation does occur in which there are no 
signs of contagion or infection. 

Etiology. — Membranous inflammatory processes of the mucous 
membrane are dependent upon two conditions — first, the systemic 
state of the individual, especially as regards the chemical con- 
stituents of the blood ; and, second, an agent irritating the mucous 
membrane. Membranous inflammation may be brought about by 
corrosive chemicals, follow scalds or burns, thermocautery, wounds, 
and inhalation of irritating vapors, and may also be caused by the 
action of certain pathogenic bacteria, such as the Bacillus diph- 



662 DISEASES OF THE LARYNX. 

therise and the Streptococcus pyogenes. In membranous croup 
the Klebs-Loffler bacillus, in its true virulent form, is not a fac- 
tor from an etiological standpoint. The membranous variety of 
inflammation may occur at any season of the year. It is especially 
common in children from the first to the sixth year. It may, 
however, occur later in life, although rarely. On account of the 
greater exposure, the disease is more common in boys than in girls. 
It frequently occurs in children as a complication of the eruptive 
fevers, especially scarlet fever and measles, or may be secondary to 
a membranous inflammation of the tonsil or pharynx ; the majority 
of cases of membranous inflammation of the larynx, however, are 
truly diphtheritic. The fact that the bacillus of diphtheria is 
found present in cases which show no contagious or infectious 
tendency renders the diagnosis between that and the so-called true 
diphtheria impossible, other than by simply watching the case. 
There has been, and still is, a great variance of opinion as to the 
contagiousness and non-contagiousness of the membranous variety 
of inflammation. Unquestionably, there are cases of true mem- 
branous laryngitis of the fibrinous variety w T hich are in no sense 
contagious or infectious. There is in many cases very little local 
clinical diiference between this condition and true diphtheria. 
Even the symptoms, course, and termination may be very much 
the same pathologically ; however, in the true, simple, non-diph- 
theritic membranous variety the false membrane is on the sur- 
face of the mucous membrane, and when stripped off shows no 
evidence of necrotic change or ulceration ; while in the diphtheritic 
form there is ulceration which perforates the basement membrane. 
In the true diphtheritic variety, however, the membranous exudate 
and acute inflammatory process are largely limited to the laryngeal 
structure. The given case of membranous inflammation may be 
purely laryngeal, which brings us back to the original question of 
diagnosis. While the local manifestations are practically the same, 
in true diphtheria the systemic infection is more marked and the 
clinical phenomena are much more pronounced. It is a safe plan 
in the beginning to treat every case of membranous inflammation 
as though it were both contagious and infectious, as it is much 
better to err on the safe side and isolate a case which is not con- 
tagious, and which in a few days, or, as often occurs, in from 
twenty-four to forty-eight hours, will be perfectly well, than to fail 
to isolate a case of true diphtheria. The prophylactic treatment 
and the treatment of the early stage will be practically the same. 
In true diphtheria the patient will not recover in twenty-four 
hours, with entire disappearance of the symptoms, nor even in 
three or four days. While it is always best to be on the safe 
side, prejudice should not carry us so far as to cause us to for- 
get the rights of our patients and the inconvenience, to which 
they may be subjected by the strictness of quarantine. It may also 



MEMBRANO US XAR YNGITIS. 663 

happen that we have placed ourselves in the annoying position of 
finding our little patient perfectly well in two or three days, and 
yet the house will be quarantined for some two or three weeks by 
the city authorities if the diagnosis of true diphtheria has been too 
hastily reported. The majority of cases of so-called membranous 
laryngitis may be really laryngeal diphtheria ; yet there is such a 
thing as membranous laryngitis which is not diphtheria. 

Pathology. — The pathological alterations in the structure are 
those of an acute inflammatory process. Poured out on the surface, 
however, either uniformly or in patches, is the croupous or mem- 
branous exudate, which consists of fibrin, entangled in the meshes 
of which are leukocytes, blood-corpuscles, and desquamated epi- 
thelial cells. The false membrane may appear in any portion of 
the larynx ; it may be above the cords, involving the ventricular 
bands or the epiglottis, or may be below the vocal cords, really 
laryngotracheal. When stripped off the mucous membrane, it 
will leave a raw, reddened surface ; slight bleeding may occur, but 
not from ulceration — due merely to capillary hemorrhage. The 
severity and character of the inflammation, however, have largely 
to do with the extent of involvement of the deeper structure. The 
virulence of the bacterial agent in one person and the non-virulence 
in another can be explained by the varying physiological resistance 
of individuals, which also explains why a case of diphtheria may 
develop from an apparently harmless or mild sore throat, or the 
reverse condition. 

Symptoms. — The symptoms of this dangerous disease are 
peculiar brazen cough, slight, stridulous breathing (both inspiratory 
and expiratory, as noticed in false croup), gradual alteration in 
voice, and peculiar hoarseness, with probably slight dyspnea. The 
fever comes on gradually. The attack of membranous laryngitis 
is usually preceded by slight cough or a catarrhal inflammation, 
with slight fever and very little alteration in voice. This may 
last from one to three or four days, with the disappearance of all 
symptoms. A slight membrane forms, with practically no con- 
stitutional symptoms, or the patient rapidly grows worse, and the 
symptoms become more pronounced. The cough assumes the 
peculiar harsh, ringing character, coupled with rapid change in 
the voice and difficult respiration. Later, there is high fever with 
marked systemic depression. The difficulty in respiration and the 
fever, however, will show marked exacerbations and remissions. 
There is excessive thirst, and the eliminative functions are per- 
verted ; the skin is dry and the bowels are constipated. This 
condition may last for several days. The child will be restless, 
the head thrown back, the respirations labored ; and the peculiar 
croupal sound never entirely disappears, although the patient at 
times is apparently much better. Frequently, portions of the 
membrane may be coughed up or vomited. There is very little 



664 DISEASES OF THE LARYNX, 

difficulty in swallowing. The cough may cease altogether. Instead 
of dyspnea that is paroxysmal, it becomes continuous ; the skin is 
livid and loses its ordinary sensitiveness ; the extremities become 
cold, and unless relief is afforded at once, death is almost certain. 
Quite frequently, when the case continues for three or four days, 
it is aggravated and the prognosis made more grave by compli- 
cating attacks of bronchitis or pneumonia. In fact, in all cases of 
inflammatory processes of the upper respiratory tract in children, 
careful attention should be paid to the lungs. The use of the 
stethoscope may aid in locating the site of the membrane in the 
larynx, although its accuracy is by no means certain. The laryn- 
goscopy examination is difficult to carry out, but will show the 
presence of the membrane, the immobility of the vocal cords, and 
the apparent binding together of the arytenoid cartilages and the 
interarytenoid space by the false membrane. 

Diagnosis. — The condition is likely to be mistaken for false 
croup or spasmodic laryngitis, acute laryngitis, edema of the larynx, 
diphtheria, retropharyngeal or retrolaryngeal abscess, tonsillitis, 
capillary bronchitis, whooping cough, or foreign bodies in the 
throat or larynx. 

Edema of the Larynx (Glottis). — The dyspnea is of the same 
degree as in croup, although more paroxysmal. The cough is 
more smothered and not so harsh, nor is respiration noisy. The 
symptoms do not disappear during the paroxysms of coughing; 
in that respect it resembles croup. Slight, if any, stridulous 
breathing occurs ; there is more marked inspiration, with profuse 
expectoration. There is very little fever. The condition is more 
common in adults, and the edema is usually associated with other 
conditions. Laryngeal examination is not so difficult. 

Diphtheria. — The expectoration is about the same as in croup. 
The pharynx and fauces may be involved in the membranous 
formation. The cough is slight and paroxysmal. Difficulty in 
breathing varies ; sometimes the interference is marked, causing 
dyspnea. The voice is not so markedly altered as in croup, and is 
more nasal in character. There is always the accompanying pecul- 
iar characteristic odor, which, once noted, is not soon forgotten. 

Retropharyngeal Abscess. — There is stridulous respiration, 
both inspiratory and expiratory, and the voice is altered. The expec- 
toration is slight and not membranous, but the cough is of a hacking 
variety. There is marked difficulty in swallowing, with external 
tenderness on pressure, and localization of the external swelling 
occurs. The dyspnea is marked, and may even be paroxysmal ; it 
is aggravated by swallowing, which is not the case in croup. The 
dyspnea is increased by pressure on the larynx, and is aggravated 
when assuming the horizontal position. This is not true in croup, 
although in membranous inflammation change of position will 
bring about paroxysms of dyspnea, on account of the shifting of 



MEMBRANOUS LARYNGITIS. 665 

the membrane. The alteration of voice in croup is one of tone, 
while in abscess-formation the patient is able to make sounds, but 
cannot articulate, and it is almost impossible to understand what is 
being said. There is tendency to edema, and it is difficult for the 
patient to open the mouth wide. 

Tonsillitis. — The breathing is not impaired, and examination 
will determine the nature of the disease. 

Capillary Bronchitis. — The dyspnea is marked but unremit- 
ting, and is associated with rales all over the lung. The cough is 
loose and the expectoration profuse. The voice is only slightly 
altered, if changed at all. 

Whooping- Cough. — There are paroxysms of coughing and 
dyspnea, followed by the distinctive whoop. There is practically 
no fever, and the voice is not husky unless irritation has been pro- 
duced by the violent coughing. Between attacks the child is per- 
fectly well. The deep cervical glands are enlarged. 

Foreign Body. — The presence of foreign bodies will give rise 
to stridulous breathing and violent spasmodic cough. There is no 
fever unless it is after inflammatory action takes place. The his- 
tory of the case will aid greatly. All symptoms will be altered as 
the foreign body changes its position. The stridulous breathing 
is more marked on expiration, as was pointed out by Gross. 

Prognosis. — The prognosis in severe cases is very grave. 
The condition lasts from four to six days. Under all forms of 
treatment the mortality ranges from 60 to 80 per cent. Exten- 
sion of the process down into the trachea or bronchial tubes renders 
the prognosis more unfavorable. 

Treatment. — The nasal passages and the pharynx should be 
thoroughly cleansed with a spray of — 

1^. Hydrogenii peroxidi, 

Extracti hamamelidis fluidi, 

Aquae cinnamomi, da flgj (30.). — M. 

Besides the above given spray, the frequently repeated use of lime 
water is highly beneficial. The atmosphere of the room in the 
beginning of the disease should be charged with steam. The best 
way to accomplish this is to form a tent of any suitable material 
over the bed, leaving a large opening at the side, near the head, 
for ventilation, the steam being introduced by means of a tin pipe 
extending from the generator, which can be an ordinary kettle 
filled with water, to which may be added oil of eucalyptus, oil of 
tar, oil of white pine, from 15 to 30 drops each to the half-gallon 
of water. In the early stages cold externally to the throat, or the 
application of crude petroleum, is highly beneficial. Several cases 
in which no other treatment was employed, the petroleum being 
used both internally and externally, were followed by highly 



QQQ DISEASES OF THE LARYNX. 

beneficial results. This remedy is almost a household one in the 
oil regions. Emetics are indispensable, for they materially aid 
in the expulsion of the false membrane, and should be repeated if 
symptoms indicate. They may afford permanent aid and hasten 
the recovery. Of the many emetics employed, one of the safest 
and best is a teaspoonful of salt in lukewarm water. 

The internal medication — in fact, the whole treatment — is very 
much the same as that of diphtheria. Minute doses of calomel, 
given every one or two hours, and continued for even two or three 
days, are very useful. Should the bowels move too freely, they 
may be controlled by opiates, the dose and its continuation being 
controlled entirely by the symptoms indicating relief of the laryn- 
geal obstruction. To sustain the patient stimulants should be 
administered, preferably whiskey or brandy, and the child should 
be sponged frequently with whiskey and water or alcohol and 
water in equal parts. The general system should also be sup- 
ported by the administration of iron preparations, the best of which 
is tincture of the chlorid, the dose graduated by the age of the 
child. A child from one to three years of age should be given 
from 3 to 10 drops, well diluted in water, every one to two hours. 
The small dose frequently repeated is better, on account of large 
doses causing gastric disturbance in children. 

Surgical Treatment. — Although the best possible treatment 
may be instituted early in the disease, it may fail to relieve the 
dyspnea which continues and threatens immediate suffocation of 
the patient. If there is a gradual increase of the stenosis, as well 
as constant dyspnea, in spite of the continued and judicious use of 
remedial agents, and if the restlessness of the child increases, while 
there is an expression of suffering in his features, with lividity of 
the surface, prompt surgical interference must be instituted, and 
should consist in either intubation or tracheotomy, the former 
offering the higher percentage of cures. The two procedures are 
considered under other and separate headings (pages 777 and 786). 

HEMORRHAGIC LARYNGITIS. 

Synonym. — Hemorrhagic inflammation of the larynx. 

Laryngeal hemorrhage and hemorrhagic laryngitis represent 
entirely different conditions. Hemorrhage from the larynx may 
occur in syphilitic or tuberculous ulceration, in malignant disease, 
from wounds, from the presence of foreign bodies ; or it may take 
place as the result of a sudden acute inflammatory process, or of 
lesion of the blood-vessel wall, or of sudden distention of the 
blood-vessel by an increased circulation. In the inflammatory 
condition the hemorrhage is secondary to the inflammation. In 
the syphilitic or tuberculous ulceration, or in malignant disease, 
while it may be associated w r ith the inflammatory process, yet the 



HEMORRHAGIC LARYNGITIS. 667 

hemorrhage is a secondary condition, the result of necrosis. True 
hemorrhagic laryngitis is rare — i. e.) the condition in which there 
are areas of hemorrhagic infarction, due to rhexis of the vessel, 
and in which the inflammatory process is secondary to the hemor- 
rhage. There is a condition, however, described under Cyanotic 
Laryngitis, closelv allied to chronic edema, in which from some 
constitutional or organic lesion, such as interstitial hepatitis, val- 
vular disease of the heart, fibroid lung, various forms of anemia, or 
contracting kidney, or any condition which interferes with the 
systemic circulation, the blood may be dammed back on the mucous 
membrane, and by pressure and overdistention the vessel- wall may 
be thinned and ruptured. This, however, is not a hemorrhagic 
laryngitis, but a laryngeal hemorrhage. Frequently, from violent 
use of the voice or of the muscles of the neck, as in violent cough- 
ing and vomiting, or even from violent exercise, the local hyper- 
emia may produce capillary hemorrhage with blood-stained secre- 
tion. This is especially true in plethoric individuals. 

Pathology. — Where the hemorrhage occurs into the tissue, 
due to the rupture of a vessel, there is a small area of hemorrhagic 
infarction. If this is in the submucosa and has sufficient collateral 
circulation, the extravasated blood will be absorbed and leave no 
permanent alteration. However, if it is sufficient to cut off the 
blood-supply partially and cause local necrosis without infection, 
the inflammatory area surrounding the area of infarction having 
good nutrition, the space will be filled with connective-tissue cells or 
granulation-tissue, and through the processes of proliferation and 
vascularization forming new tissue, give rise to slight scar-forma- 
tion. The same condition is found in the lung and in the kidney. 
The epithelial cells covering the area of infarction will desquamate. 
If the basement membrane is also intact, with re-establishment 
of circulation there will be re-formation of the epithelial layer. 
If, however, the area undergoing necrosis be of any considerable 
extent, at least sufficient to prevent the filling in of the epithelium 
from the sides, a scar will be the result. 

Symptoms. — The laryngeal irritation is only slight. There 
is a sensation of irritation in the throat, with a slight tendency to 
cough. The alteration in the voice, if the area of hemorrhage 
involve the vocal cords, will be marked. If the vocal cords or 
ventricular bands are not involved, there may be no alteration in 
the voice. The extent of the extravasation will determine the 
interference with breathing. If the hemorrhage is sufficient to 
obstruct breathing, it should be classed under hematoma and not 
considered as a simple hemorrhagic infarction, although the process 
differs only in degree. If the hemorrhage be on the surface, the 
saliva will be blood-tinged. If it is within the submucosa, con- 
stituting a true hemorrhagic infarction, there may be no evidence 
of blood in the secretion. 



668 DISEASES OF THE LARYNX. 

Diagnosis. — In the differential diagnosis, inspection will de- 
termine as to whether the hemorrhage occurred within the naso- 
pharynx, the pharynx, or the tonsil, either pharyngeal, faucial, 
or lingual. When the hemorrhage occurs below the vocal bands, 
either within the larynx, trachea, or lung, the blood will be mixed 
with mucus ; however, when it is from the larynx, no evidence of 
rales in the lungs will be detected, and while the mucus may be 
blood-stained, it is not thoroughly mixed. Quite frequently the 
laryngoscope will determine the localized spot from which the 
hemorrhage has taken place. 

Prognosis. — The hemorrhage from the larynx is not alarming, 
and is rarely ever fatal ; in fact, laryngeal hemorrhage is rarely 
ever attended by pulmonary hemorrhage, unless associated with 
advanced pulmonary tuberculosis ; then the history and condition 
of the individual will determine the diagnosis and prognosis. 

Treatment will depend entirely upon the cause. If the ex- 
travasation is sufficient to cause a hematoma, it should be incised 
and the clot excavated. The small hemorrhagic areas will undergo 
absorption or reorganization. If the hemorrhage is from the sur- 
face and is in quantity sufficient to cause alarm, cold applications 
should be made to the back of the neck. There should 
be administered internally a grain of ergotin every hour for 
two or three doses, or until the physiological effect is produced. 
To allay the tendency to cough and to clearing the throat, y 1 ^- to 
^ grain of codein should be administered every three hours. When 
the cause of hemorrhage is determined, whether it be local or 
constitutional, the patient should be instructed in the amount of 
exercise compatible with his condition. The intralaryngeal appli- 
cation of astringents is of questionable benefit, as the spasm and 
irritation produced by the introduction of the applicator into the 
larynx are likely to cause local congestion and aggravate the very 
condition it is aimed to relieve. If the solution can be applied by 
means of a laryngeal atomizer, beneficial results may be obtained ; 
but, as a rule, very little of the solution goes into the larynx when 
applied in this manner. Of the astringents, alum, gr. \ T -x, and 
tannic acid, gr. iij-vj, to the ounce, will give the best results. 
Careful attention must be given to the systemic condition, and any 
vascular, organic, or intestinal irregularities corrected. 

CHONDRITIS AND PERICHONDRITIS. 

Chondritis of the larynx, or inflammation of any of the car- 
tilages of the larynx, is so closely allied, both from an etiological 
and symptomatical standpoint, to perichondritis that both will be 
considered under the same heading. 

Ktiology. — Traumatism, such as blows (direct or indirect), 
gunshot wounds, stab wounds, choking or grasping of the throat, 



CHONDRITIS AND PERICHONDRITIS. 669 

often produces an inflammation of the cartilage or its perichon- 
drium. Either by infected emboli or through the mucous mem- 
brane, septic or specific micro-organisms gain access to the peri- 
chondrium and produce perichondritis. Foreign bodies, too, 
finding lodgement in the esophagus and causing wounds, may 
produce a perichondritis or chondritis in the larynx by perforating 
or irritating the posterior portion of that structure. Rheumatism 
or gout may play the role of etiological factor, and produce a peri- 
chondritis which, while occurring at any age, is most often seen 
in adult or middle life, and is but one of the group of symptoms 
which go to make up the disease. 

Any of the specific inflammations, especially syphilis, tubercu- 
losis, actinomycosis, and glanders, may bear causal relations to the 
condition. By direct involvement or by pyemic metastasis peri- 
chondritis or chondritis may occur in small-pox, diphtheria, and 
typhoid fever. To the last cause such a large proportion of cases 
is attributable that much of value has been written concerning it. 
Tumors, either malignant or benign, within the larynx or situ- 
ated immediately surrounding it, may produce this condition. A 
number of observers have assigned as a cause of perichondritis 
pressure of the plates of the cricoid against the vertebrae in aged 
people, or in those whom illness and weakness ccmpel to lie con- 
stantly in bed. The generally bad nutrition, combined with the 
local pressure and irritation from the bolus of food as it passes 
into the esophagus, produces, so to speak, a laryngeal bed-sore. 
Exposure to damp or cold, sudden chilling of the body, overuse 
of an inflamed larynx in talking or singing, may cause a painful 
inflammatory involvement of any or all of the cartilages of the 
larynx or their perichondrium. 

Pathology. — Syphilis. — The pathological alterations occur- 
ring in syphilitic chondritis or perichondritis in the larynx do not 
differ from those seen in other cartilages. The mucous patch 
sometimes occurs in the larynx, coming on in the same manner as 
similar lesions in the mouth. Deep ulceration is an evidence of 
tertiary involvement, and is usually seen from three to five years 
after the primary infection, although it may occur much later in 
life. In syphilitic gumma of the larynx there is first noticed 
beneath an unbroken mucous membrane a grayish-yellow nodular 
projection, which gradually undergoes ulcerative changes, modified, 
as are all superficial inflammations, by the condition of the sur- 
rounding structure. Infiltration into the submucosa may now 
come on, or may have preceded this stage and produced a sudden 
and alarming edema. Hemorrhage too occurs, which may emanate 
from any spot in the larynx that has been the seat of ulceration, 
from the epiglottis to low down in the trachea. When these 
ulcerative areas begin to heal of themselves or under appropriate 
treatment, there is left a peculiar stellate cicatrix, which on con- 



670 DISEASES OF THE LARYNX. 

tracting causes stenosis and brings about an alteration in the voice, 
not only from the mere amount of structure involved, but also by 
displacement of the cartilaginous structure. Adhesion of the vocal 
cords or ventricular bands may occur. 

Tuberculosis. — Involvement of the larynx by tuberculosis 
may develop primarily by localization of the nodule, or may ex- 
tend by way of the soft tissues from some surrounding infected 
area. There is usually a great deal of edema in tubercular peri- 
chondritis, which impedes the motion of the larynx and causes 
marked alteration in the voice. In the early stage there is but 
little ulceration ; but as the disease increases in intensity, the 
edema grows less, and an ulceration of a shaggy gray color begins 
to slough its way around the larynx, generally commencing from 
behind and working toward the front. Even after the ulceration 
occurs, there usually remains a certain amount of edema that is 
apt to be permanent. The secretions are tenacious and adherent. 
Later still, necrotic or gangrenous changes may involve the carti- 
lage by their interference with the circulation. Fungous growths, 
the so-called tuberculous granulomata or papillomata, may be seen 
springing from the edge of the ulcerated area. 

Typhoid Fever. — Commencing with hyperemia and congestion, 
there rapidly follows an inflammatory edema, with exudation into 
the surrounding or adjacent soft structure, which, on account of the 
location and the limit set by the cartilaginous wall of the larynx, 
must extend inward, and rapidly lessens the lumen of the larynx. 
This edematous stage and the stage of ulceration which has gone 
on to necrotic involvement of the cartilages differ only in degree, 
but not in kind. The cartilages of the larynx are at best poorly 
supplied with blood, rendering them at all times susceptible to 
necrotic change. When during the course of typhoid fever the 
nutrition is lowered throughout the body, circulation in this locality 
suffers to a greater extent, as it is dependent on surrounding tissue 
for its blood-supply, and rapidly undergoes necrosis, which may 
slough out in small portions or be discharged en masse. This 
breaking down of tissue, as in abscess-formation, may penetrate 
toward the point of least resistance, rupture, and virtually form an 
ulcer. In the majority of instances of perichondritis or chondritis 
due to typhoid fever I believe that the infection and inflammatory 
process are similar to those seen in abscess-formation, which, making 
for the point of least resistance, open in ulceration on the mucous 
surface. The typhoid bacillus is usually found present in the 
necrotic mass. The ulceration is commonly situated posteriorly, 
and the cartilaginous involvement is on the side and toward the 
back part of the larynx. By reason of the character of the blood- 
vessel topography, thrombosis is most likely to take place in this 
posterolateral area, with the added weight of the decubital posi- 
tion, as has been explained before. If only a part of the cartilage 



CHONDRITIS AND PERICHONDRITIS. 671 

has been destroyed, and the perichondrium remains, there may be 
a reproduction of the cartilage, which has practically taken place in 
a case now under my observation. In any event, it is likely that the 
abscess will be followed by a fistula, and it is always to be remem- 
bered that suppuration without necrosis of the cartilage — which is 
nothing more than abscess-formation — may occur, though it is an 
exceedingly rare condition. 

Traumatism ; Rheumatism. — In chondritis and perichondritis 
due to these causes, the exudation and swelling may go on to 
absorption and resolution. A similar result may be noticed in 
typhoid fever, though in this disease, as in syphilis and tuber- 
culosis, there is nearly always suppuration, with necrosis of the 
affected cartilage. This is especially true of the cricoid and the 
arytenoid involvement. In this latter group a purulent exudate 
may exist for months or years until all the necrosed tissue has 
been exfoliated. However, prompt treatment and thorough 
removal of all diseased structure are usually demanded by the 
severity of the symptoms long before nature has removed it. In 
all of the varieties the process ordinarily begins about the cartilage 
as a perichondritis, the cartilaginous involvement being secondary. 

Order of Involvement of Cartilage. — The cricoid cartilage is 
usually involved to greater extent and oftener than any of the 
others. Its inner surface is, as a rule, implicated by marked 
tumefaction. The arytenoid cartilage is next in order, usually 
unilateral, and, like the cricoid, implicates both the air- and the 
food-tracts. Necrosis will generally occur much earlier in the 
arytenoid than in the cricoid. Either surface of the thyroid carti- 
lage may be involved, the outer or inner, one or both wings, but 
commonly it is unilateral with an internal involvement. As the 
thyroid cartilage has a better blood-supply than either the cricoid 
or arytenoid, extensive necrosis is not so likely to occur when it is 
a part of a general involvement. The epiglottis is seldom involved 
primarily, but may be, by extension from the adjacent cartilaginous 
structure. The tracheal rings, too, may become involved. After 
any implication that has gone on to necrosis, the tissue may organ- 
ize from the surrounding healthy structure, and give rise to a caving 
in of the necrotic area, with subsequent scar-tissue. 

Symptoms. — The symptoms of chondritis and perichondritis 
are almost identical, and the diagnosis between the two is of little 
import, as in either case treatment is practically the same, both 
demanding constant attention and being controlled to a great 
extent by the symptoms as they arise. 

Syphilis and Tuberculosis. — The symptoms occurring in peri- 
chondritis or chondritis due to either of these causes are to a great 
extent the same. They resemble those seen in chronic laryngitis, 
except that there is more pain in the tubercular variety, which 
increases as the ulceration goes on. The previous history of the 



672 DISEASES OF THE LARYNX. 

case is to be carefully determined in order to differentiate the 
actual underlying cause. In both syphilitic and tuberculous cases 
there is usually a slight rise of temperature. The edema in the 
tuberculous instances may be so alarming as to produce symptoms 
in the respiratory tract of such moment as to necessitate immedi- 
ate tracheotomy. Deglutition too is very painful, due to the fact 
that the posterior part of the larynx is usually involved. Later 
on there may be partial or complete aphonia due to the loss of the 
cartilaginous framework. Spontaneous rupture, if it occurs, takes 
place into the larynx or, possibly, into the pharynx. If the epi- 
glottis is involved — an exceedingly rare complication — it only 
adds to the gravity of the case by the extent of involvement. In 
syphilis there is sometimes a peculiar odor from the secretions, 
suggestive of their specific origin. There is marked pain in both 
varieties, increased on swallowing. 

Typhoid Fever. — When chondritis or perichondritis occurs as 
a complication of typhoid fever, attention may not be directed to 
the larynx on account of the apathy of the patient, so that it may 
be several days before it is recognized. Hoarseness is quite a com- 
mon complication of typhoid fever, with slight dysphagia. These 
may persist well along in convalescence, and suddenly, from a 
slight cold or exposure, swallowing becomes more painful, and the 
hoarseness increases. The onset from now on is very apt to be 
rapid, and in a few hours marked difficulty in breathing and 
suffocative attacks may supervene. Laryngeal stenosis sets in, 
with stridor, inspiratory depressions of the neck and chest-walls, 
and rapid respiration that is labored and exhausting. The auxili- 
ary muscles of respiration are called into use ; owing to the lim- 
ited lung-expansion occasioned by the quick, short respiration, 
mucus accumulates and the respirations become noisy. Dyspnea 
becomes marked, and nourishment can be taken only with diffi- 
culty. The expectoration is not greatly increased. Attacks of 
suffocation come closer together, and are more terrible. The 
face becomes livid, and there is the unrest of despair. Trache- 
otomy may now have to be done to prevent suffocation, The 
symptoms may subside before reaching such a point, although with 
each recurring attack they become more alarming. Occasionally, 
discharge of pus and necrosed cartilage, from the breaking down 
of the affected area, may give relief to the patient. There is like- 
lihood, however, of recurrence, or even of a permanent fistula. 
One case was seen in my office in which there had been necrosis 
of the first tracheal ring on the right as a sequel to typhoid fever ; 
the swelling was pronounced, both externally and internally. The 
tissue had broken down, and there was discharged a portion of 
the cartilage. After the discharge of the necrosed cartilage the 
patient made an uninterrupted recovery. The temperature is not 
usually as high as in acute abscess, although there is considerable 



CHONDRITIS AND PERICHONDRITIS. 673 

fever. The condition drags along for days and weeks. Cases of 
suffocation, as shown by Keen, are those in which the marked 
dvspnea and suffocating attacks occurred early or from the acute 
inflammatory swelling. If the perichondritis be due either to the 
Bacillus typhosus or to pus-organisms, there will inevitably result 
necrotic changes, with complete or partial destruction of the car- 
tilage. The symptoms are most intense and severe, and the 
danger of suffocation from edema is most marked in the earlier 
stage, when it is limited to the perichondrium, and the obstruction 
is due to the edematous swelling. The acute stage is soon com- 
pleted. The symptoms are less marked in the chronic stage, 
being modifications for the better of the symptoms of the primary 
or acute condition. There is, however, as a rule, a typhoid state 
or condition of weakness not the result of the chondritis, but of 
the fever. Emphysema of the tissues of the neck may occur, due 
to a perforating ulcer in the posterior wall of the larynx. The 
suppuration may extend down into the mediastina. Both of these 
complications are rare, but of exceedingly serious import, and it is 
to be noted that all of these laryngeal implications are more 
common in adults than in children, and may involve any or all of 
the cartilages of the larvnx. Necrosis of the cartilage is common 
and extremely dangerous, the mortality running as high as 95 per 
cent, of the cases involved. Keen has shown in his Toner Lectures 
and in his Surgical Complications and Sequels of Typhoid Fever 
that the fatal cases usually have edema of the lung. Laryngo- 
scopical examination will reveal that in the majority of cases the 
broad posterior plate of the cricoid cartilage is affected. Be the 
perichondritis where it may, its site will show as an irregularly 
nodular and unilateral inflammatory swelling distinctly outlined. 
Sometimes ulcers may be seen on the posterior laryngeal wall or 
on the vocal cords. The area involved, covered with a mucous 
membrane red, boggy, and edematous, may bulge out and encroach 
upon the subglottic space or press on the vocal cords, or may be 
located posteriorly. The vocal cords, epiglottis — in fact, all the 
surrounding tissue — may be markedly swollen and congested. If 
the perichondrium of the thyroid cartilage be inflamed on its 
inner surface, it will present a smooth, red swelling around and 
involving the ventricular bands. If the entire perichondrium be 
involved, the swelling will be external also, and there will be a 
localized point of tenderness. Muscle-paralysis may result from 
this inflammatory process, more commonly seen in men than in 
women. A rapid rise of temperature may, in the course of an 
otherwise uneventful convalescence from typhoid fever, be accom- 
panied by pain in the larynx, besides dysphagia, if the involve- 
ment be posterior, not so marked if it be anterior. In addition 
to these symptoms, dyspnea that is inspiratory and aphonia that 
may vary from complete to any degree of partial loss of voice, 

43 



674 DISEASES OF THE LARYNX. 

with a tendency to choking attacks or suffocation later on, point 
toward the diagnosis of perichondritis or chondritis following 
typhoid fever. 

Rheumatism, Traumatism, Exposure to Cold, etc. — The 
earlier symptoms of perichondritis or chrondritis due to any of 
these causes are not very characteristic, but there is usually some 
hoarseness, with pain localized to an individual point or area, 
especially developed by movement or pressure externally. Again, 
efforts at swallowing or talking will cause a varying amount of 
discomfort or pain in the larynx. The voice may later become 
hoarse, and a cough may develop. Dysphagia and, later, dyspnea, 
with perhaps stridor or suffocative attacks that are paroxysmal, 
will develop, and finally stenosis may occur. When the abscess 
is evacuated, either artificially or unaided, pus and the product of 
the inflammatory degeneration are expectorated and the symptoms 
ameliorated. 

Cricoid Cartilage. — If the cricoid cartilage be the seat of 
involvement, the posterior surface is most likely to be infected, 
owing to its exposure to friction. Here the inflammatory process 
usually proceeds from the upper articular surface toward the ary- 
tenoid cartilage, so that, if the condition be far advanced, the 
arytenoids are usually involved, the swelling involving an area 
similar to perichondritis of the arytenoid cartilage. It is most 
typical when seen beneath the true vocal cord, where it shows 
as folds or convolutions. Dyspnea that is both expiratory and 
inspiratory occurs, with marked dysphagia and loss of voice in all 
cases, either permanent or temporary, which may be due to direct 
involvement of the cords, to watery infiltration, or to involvement 
of the cartilage or muscle. Cough of varying character is nearly 
always present. 

Arytenoid Cartilag-e. — Perichondritis of this locality is very 
common ; the swelling is seen over the cuneiform cartilage, with 
an abnormality of movement and a delay in the action of the vocal 
cords. The swelling internally resembles closely a cold abscess, 
and may extend beyond the true vocal cords. If the cricoaryte- 
noid joint is involved, ankylosis or necrosis may result, with a 
change in the voice that amounts to permanent alteration, or loss 
in the severer cases. 

Thyroid Cartilage. — If the involvement be external, the 
swelling of the alse can be felt and seen. Both within and with- 
out the larynx, pain is localized. There may be an inward bulging 
between the vocal cords in the anterior angle. The voice is 
markedly altered, respiration and deglutition are interfered with, 
and such symptoms as edema, dyspnea, and dysphagia vary pro- 
portionally with the extent of involvement. If the entire thyroid 
cartilage be involved, the termination is usually fatal. 

Perichondritis of the smaller cartilages cannot be recognized 



CHONDRITIS AND PERICHONDRITIS. 675 

clinically. It is to be noted that ossification of the cartilages of 
the larynx occurs, as a rule, as old age approaches. This is not a 
pathological process. The only significance is that inflammation 
in these localities is less likely to occur than before. 

Fibrous degeneration in the cartilage is an extremely rare 
condition, and while possible, no well-authenticated cases have 
been reported. 

Diagnosis. — Syphilitic Perichondritis. — In making the 
diagnosis in syphilitic perichondritis, the previous history of the 
case is to be carefully searched for any specific manifestation, going 
back a decade of years, if necessary, in the search. Syphilitic 
manifestations elsewhere in the body are to be carefully looked for. 
The lungs are to be diligently examined, and absence of lung- 
involvement points rather toward the diagnosis of syphilis than 
tuberculosis, as a tubercular condition of the larynx is rarely ever 
primary. There is more likely to be external swelling in syphilis 
than in tuberculosis. There is a tendency to heal in syphilitic in- 
volvement that is not seen in tuberculosis and carcinomata. The 
ulceration of tuberculosis is more extensive and has a rather worm- 
eaten appearance, which is not the case in syphilis. Secretions are 
fairly profuse in syphilis, and there is a marked odor. 

Tuberculosis. — Early in tubercular involvement the mucous 
membrane is pale, and peculiar, circumscribed, nodular areas of 
tumefaction are noticed, especially about the supra-arytenoid ex- 
tremity of the aryepiglottic fold. These points of involvement 
are frequently most marked posteriorly. They may or may not be 
found on the same side as the affected lung. The history of the 
individual case, of his correlatives, and of his progenitors is to be 
carefully obtained, with a view to establishing an inherited pre- 
disposition toward tubercular infection. The sputum should be 
examined for the presence of the tubercle bacilli. The edema of 
tuberculous perichondritis is more apt to be chronic than that 
occurring in syphilis. When ulceration occurs, it is of an irregu- 
lar shaggy appearance, covered with greenish tenacious pus, sur- 
rounded with papillomatous proliferation. This ulceration usually 
extends from below upward, while the ulceration of syphilis extends 
from above downward. 

Typhoid Fever. — The diagnosis of the perichondritis or chon- 
dritis following typhoid fever involves, as a rule, no difficulty as 
to causation, and the symptoms of the condition, already given, 
will render it plain. 

Rheumatism, Traumatism, Exposure to Cold, etc. — In peri- 
chondritis or chondritis due to rheumatism or gout it is rare to 
find an entire absence of manifestations in other parts of the body. 
The urinary examination will do much toward establishing a diag- 
nosis in doubtful cases. 

The history of the case, showing that some time previous the 



676 DISEASES OF THE LARYNX. 

external tissues of the throat have been roughly handled or injured, 
or harm has been done internally to the structure, will make clear 
the cause of the condition under the head of Traumatism. The 
laryngeal pictures of all of the conditions due to this group of 
causes is so similar that the history of the case alone will decide 
to which subdivision it properly belongs. 

Prognosis. — Tuberculosis. — The outlook for tubercular peri- 
chondritis is bad, although the disease may persist for a number 
of years. If the larynx is seriously involved, cure is not possible. 
All cases of pulmonary tuberculosis are not complicated with laryn- 
geal tuberculosis, though, when associated, the throat-condition may 
apparently come and go. 

The outlook for syphilitic perichondritis, while not favorable, 
is better than for the tubercular variety, and depends largely on 
the length of time that the condition has existed before it came 
under medical notice, and the skill with which appropriate medi- 
cation is administered. 

Following typhoid fever, the outlook for perichondritis or 
chondritis depends largely on the general condition of the patient. 
At best the prognosis is bad. 

In perichondritis due to injuries, rheumatism, exposure to 
cold, etc., the prognosis is far more favorable. 

Treatment. — Tuberculosis. — In the treatment of tubercular 
perichondritis or chondritis the most rigid attention should be 
given to the building up of the patient's health and increasing his 
powers of resistance. If possible, he should be instructed to live 
in a temperature and climate suited to his needs, such as Colorado, 
New Mexico, or California ; clothing should be worn of a charac- 
ter to protect amply without fatiguing ; a diet that is at once 
nutritious and easily assimilable should be prescribed. Exercise 
that is stimulating without exhausting should be freely indulged 
in, and rest that is refreshing to the affected parts and to the 
economy at large should be gained by regular hours for sleep in 
a properly ventilated and quiet bed-chamber. The digestive tract 
should be most carefully watched over, as upon the proper dis- 
charge of this function hangs any hope for ultimate success in 
medicinal treatment. Cod-liver oil in the winter, with the hypo- 
phosphites or lactophosphate of lime in the summer, malt prepara- 
tions, quinin and iron, should be given freely. The internal 
administration of the carbonate of guaiacol, in 3-grain doses every 
three hours, is one of the best internal medicaments. If the con- 
dition is far advanced, treatment will be of no avail. 

Syphilis. — The treatment of syphilitic perichondritis or 
chondritis follows along the same line as fully laid down on 
pages 152 and 701. The iodids should be pushed to the point of 
full tolerance, and if not well sustained, or causing an excessive 
flow of secretion, mercury should be substituted, and administered 



SIMPLE CHRONIC LARYNGITIS. 677 

to the point of physiological tolerance. Failing with either of 
these drugs alone, they should be administered conjointly, rein- 
forced by the giving of such tonics as iron, arsenic, quinin, and 
strychnin. The possibility of sudden closure of the glottis due 
either to spasm or to edematous enlargement should always be 
borne in mind, and tracheotomy well below the seat of infection, 
or intubation if the involvement be high up, should be resorted to 
promptly. 

Typhoid Fever. — Scarification, in addition to puncture, inter- 
nal and external, may be resorted to early in this affection. In 
simple edema, intubation may be successfully performed ; but it 
offers little hope if the perichondritis has gone on to suppuration, 
with necrosis of the cartilage. The moment perichondritis is 
recognized and suffocative attacks occur, tracheotomy should be 
performed early, before the patient becomes exhausted. The dis- 
eased area can be better explored and medication more intelligently 
administered after the tracheotomy. Strictures caused by scar- 
tissue after necrosis may necessitate the wearing of a tube. Dilata- 
tion with bougie and wearing of special cannula are wearisome, 
and give only questionable results. External application of ich- 
thyol and lanolin, in equal parts, is highly beneficial in reducing 
the swelling by absorption. 

Traumatism, Rheumatism, Exposure to Cold, Etc. — In 
the early stages of perichondritis due to any of these conditions, ice 
externally, the cold pack, and ice to hold in the mouth until it is 
melted, should be given. Failing in this way to promote resolu- 
tion, incision should be made into the involved area, from within 
or without, to afford proper drainage. Absorbents externally 
should be applied. Any underlying systemic pathological condi- 
tion, as in rheumatism, should be combated by the proper internal 
medication. 

SIMPLE CHRONIC LARYNGITIS. 

Synonym. — Chronic catarrh of the larynx. 

Definition. — A chronic inflammatory process involving the 
superficial or deep structures of the larynx, causing structural 
alteration. The variety usually described as subacute is the begin- 
ning of the chronic inflammatory process, and only differs in that 
the structural alteration is not so marked if the lesion is arrested 
in that stage. It is characterized by hoarseness or loss of voice, 
and may lead to ulceration. 

Etiology. — Simple chronic laryngitis may be associated with 
or a result of repeated attacks of catarrhal inflammation of the 
mucous membrane, either of the larynx or of the continuous struct- 
ures above. When associated with inflammatory lesions of the 
upper respiratory tract, the existing inflammation in the larynx 



678 DISEASES OF THE LARYNX. 

may be due to the spreading of the inflammatory process by con- 
tinuity of structure ; but it is most likely to be due to the fact that 
the cause which produces the lesion above is responsible for the 
laryngeal inflammation. In catarrhal inflammations where the 
secretions accumulate about the larynx and in the esophagus, and 
by their irritating action may set up inflammatory processes, the 
condition is further aggravated by the constant effort on the part 
of the patient to clear his throat. Inflammatory conditions of the 
esophagus, spreading by contiguity of structure, may be the cause 
of the chronic laryngitis. Quite frequently, laryngitis exists as 
the result of epidemic influenza, ordinarily known as la grippe, 
where, during the attack, the laryngeal mucous membrane becomes 
infiltrated with inflammatory material which seems to differ from 
the ordinary inflammatory exudate, and has a marked tendency to 
remain permanent. Constant and continued exposure to air satu- 
rated with irritating gases or fumes will, by their irritating action, 
keep up a catarrhal condition and cause chronic inflammation. 
Systemic conditions with altered circulation are also predisposing 
causes. In individuals in whom nasal obstruction exists, the 
forced mouth-breathing and direct inhalation of dust or of air not 
properly moistened, as well as the constant irritation, will produce a 
continued inflammation of the larynx, bringing about chronic lesion 
with permanent alteration in structure. Excessive and incorrect 
use of the voice is also an exciting factor. This is especially noted 
in orators, open-air singers or speakers, and revivalists — who are 
most susceptible to this form of laryngitis. A number of patho- 
logical alterations may be produced in the larynx from continued 
or extreme use of the voice. Following the forced anemia of the 
laryngeal structures, owing to the muscular action during speak- 
ing, there is, when the parts are at rest, a reactionary engorgement. 
This repeated often day and night will bring about permanent 
dilatation of the vessels, with paresis or partial paralysis of the 
vasomotor nerves ; or from the violent efforts in speaking and the 
weakening effect of the rapid vascular changes on the blood-ves- 
sels, there may take place minute hemorrhages in the submucosa, 
bringing about really a hemorrhagic laryngitis and, quite fre- 
quently, permanent structural alteration. In a number of cases 
this will explain the loss of voice where the hemorrhagic area, 
from its involvement of peripheral terminal-nerve filaments, with 
the alteration in structure from organization, interferes with the 
action of the cords and causes incomplete phonation. Intestinal 
lesions, especially chronic constipation, through their effects on cir- 
culation, are also important factors. 

The irritation and overstimulation, as seen in tobacco-users 
and alcoholics, are also important etiological factors. The same 
is true of irregularities in the pharynx, such as an elongated uvula 
or enlarged faucial or lingual tonsils. I think this is especially 



SIMPLE CHRONIO LARYNGITIS. 679 

true of the lingual and faucial tonsils. Atmospheric conditions 
in themselves are not important factors, but when there are asso- 
ciated lesions, atmospheric changes are important as causal factors. 
The occupation of the individual must also be taken into con- 
sideration, although that strictly comes under inflammations 
brought about by mechanical irritants. The alteration in the 
voice from maldevelopment of the larynx, or irregularities in 
the formation or development of the organs of phonation, must 
not be confused with chronic laryngitis. The correction of such 
irregularities really comes under a separate specialty — that of 
defects of speech. It might be well to add a few words re- 
garding the effect of impairment of speech on the mental 
development of children. Many children are allowed to grow up 
neglected, being impressed with the fact that they are dull and not 
of the same mental caliber as their playmates, simply because they 
cannot talk as well as other children, and many of them are 
allowed to go through life with a blunted mental capacity, whereas 
if the defect of speech had been corrected early in life, such mental 
deficiency would have been averted. 

Pathology. — The pathological alteration varies largely as to 
cause. Where irritation is continued, and the slow inflammatory 
process permits of proliferation of the inflammatory exudate and 
fixed connective-tissue cells, giving permanent increase in the con- 
nective-tissue elements of the submucosa; or the thickening of 
tissue may also be due to engorged blood-vessels causing perma- 
nent dilatation and secondary change from pressure in the perivas- 
cular tissue ; in either case the epithelial layer of the mucous 
membrane, which is dependent upon the submucosa for its nutri- 
tion, will be affected. This inflammatory process may be limited 
to the laryngeal mucous membrane or may involve the deeper 
muscular structure. In cases in which the deeper structure is 
involved, the symptoms are more marked, and the tendency to 
permanent pathological alteration is increased. Where involve- 
ment of the cartilage and muscles — in fact, any of the deeper struct- 
ures — takes place, the alteration in the voice is more pronounced. 
Permanent thickening of the mucous membrane involving the 
ventricular bands will also alter the true cords, if not by inflam- 
matory process, certainly by the altered circulation and involve- 
ment of the intrinsic muscles. There is in some cases a slight 
increase in the lymphoid structure of the larynx. Where the con- 
nective tissue is markedly increased from the inflammatory change, 
permanent alteration in the tone and character of the voice will 
take place. This may be due to contraction of the organized 
inflammatory tissue, with its direct effect on the muscles and car- 
tilages involved in phonation, preventing the perfect approxima- 
tion of the cords. In cases where contraction does not occur, the 
thickening in the connective-tissue element, involving as it does 



680 DISEASES OF THE LARYNX. 

the base of the cords, renders that structure more highly vascular, 
showing the tortuous vessels on the surface and causing perma- 
nent alteration in the character of the voice. 

Symptoms. — The symptoms of chronic laryngitis are marked, 
objectively and subjectively, on attempted use of the voice. The 
voice is irregular and jerky, and the individual complains of 
throat-ache and muscle-tire. When the voice is at rest, there 
is very little to call the patient's attention to his laryngeal 
condition. There may be a slight sensation of dryness or 
irritation. In the mornings and after meals the secretions are 
profuse, exciting sufficient irritation to cause constant hawking 
or cough. On attempting to use the voice a tickling sensation is 
created in the larynx, which interferes with phonation through 
the necessary coughing. Quite often the individual may be 
able to pronounce a few words — in fact, sentences — when the 
voice will suddenly disappear, only to return as suddenly. Fre- 
quently the patient complains of a peculiar raspy feeling, and, 
as he will often express it, as if something was tearing loose 
in his throat. The effect on the voice, however, differs in indi- 
viduals. Frequently it is very husky at first, but after using 
for a few minutes the tone clears up. This is due to the 
fact that the muscular action brings about forced anemia of the 
parts, allowing free action of the cords. The condition, however, 
is only temporary, and when the parts are relaxed, reactionary 
congestion rapidly takes place, with complete loss of voice. 

If the laryngeal inflammation is uncomplicated, the secretions 
are usually not so copious, though very tenacious, and the color 
varies from a frothy-white to a yellowish-gray or even yellowish 
pus-like secretion. Occasionally the secretion is slightly blood- 
stained, either due to capillary hemorrhage following excessive 
use of the voice, or possibly to capillary hemorrhage from the vio- 
lent paroxysmal coughing. Inspection of the membrane shows a 
peculiar reddish, boggy, or edematous appearance. Blood-vessels 
may be distinctly outlined on the epiglottis or even within the 
larynx. The tissue at the base of the cords and within the ven- 
tricular bands will be injected and swollen (Fig. 223). Most 
frequently the inflammation is situated in these structures, and 
the vocal cords are involved secondarily. Normally the vocal 
bands receive their blood-supply by osmosis, and it is only during 
hyperemia or congestion that vascularization of the cords shows 
distinctly. The inflammatory process may be limited to one side, 
or may involve both cords or the entire larynx. 

As a rule, the posterior part shows the most inflammatory proc- 
ess. The appearance, as observed by inspection, of course varies 
in individuals, and is also controlled by the severity of the case 
and the stage of the inflammatory process. Alteration in the 
vocal cord is influenced more by the inflammation of the sur- 



SIMPLE CHROXIC LARYNGITIS. 681 

rounding tissue than by the actual cord-structure. This tissue 
may be permanently thickened, and while affecting the cords also 
affects the supporting structures, which interferes with the mech- 
anism of vocalization and phonation. Thickening of the inter- 
arytenoid folds may also take place, and interfere with the approx- 
imation of the arvtenoid cartilages, causing irregular action of 
the cords, and thereby affecting the voice. Any irregularity, 
either in the cord or surrounding structure, which prevents 
approximation, necessarily causes irregular action, throwing 
more stress upon one than the other, and producing permanent 
alteration. Superficial ulceration may take place, or, more likely, 
localized spots of desquamation may appear. This is most com- 
monly noted between the arytenoid cartilages. The ulceration, 
however, may involve deeper structures, followed by organized 
granulation-tissue or trachoma. It is a noticeable fact that in 
singers or speakers reactionary congestion does not always pro- 
duce hoarseness. 

Diagnosis. — Simple chronic laryngitis may be confounded 
with edema, paralysis, malignant growths, tuberculosis, and 
syphilis. 

Edema. — The swelling is more marked and comes on rapidly. 
There is very little difference in the color, although the tissue is 
more water-soaked. It runs a rapid course, and is accompanied 
by dyspnea. 

Paralysis. — There is very little, if any, swelling. There is 
present the peculiar characteristic odor from retained secretion. 
The hoarseness is always the same. Absence of motility of the 
larynx is a feature. 

Chronic Laryngitis. — The hoarseness varies, and is worse in 
the morning and after meals. The voice constantly changes in 
character, being irregular and jerky. There is absence of motility 
of the larynx, although it is not so marked as in paralysis. The 
forced use of the voice may clear it for*a time, but afterward the 
symptoms all return, usually each time with increased severity — 
not true in paralysis, edema, syphilis, or tuberculosis. The history 
in any case is an important factor. 

Tubercular Laryngitis. — The general condition and history of 
the patient are of great importance. The existence of associated 
tubercular lesions, especially of the lung, should be carefully 
sought for, and examination of the sputum will go far toward 
establishing a diagnosis. The temperature of tubercular laryn- 
gitis is apt to follow the general type of phthisis. There is also 
an irregularity in pulse, with night-sweats and a constant pain in 
the throat, increased on swallowing. This last fact is not true in 
chronic laryngitis. In tubercular laryngitis the mucous membrane 
is pale, ragged and shaggy in appearance, especially if ulceration has 
set in. In the pre-ulcerative stage there exists a catarrhal con- 



682 DISEASES OF THE LARYNX. 

dition in which there is practically no discoloration, but rather a 
nodular appearance ; but if the membrane be reddened, it is unevenly 
so. Tubercular conditions usually involve the deeper structures, 
and ulcerate ; they are usually located posteriorly, and extend 
thence around the larynx, following the line of the circulation and 
lymphatics — a fact not observed in simple laryngitis. The swell- 
ing is most marked in tuberculous conditions beyond the area of 
infection. Ulceration and erosion are not common in simple lar- 
yngitis, while in the tubercular variety it is almost characteristic. 
There is little tendency to heal in tubercular lesions, and hence 
no scar-formation. 

Syphilitic Laryngitis. — As in the other conditions, the history 
is of great importance. The " therapeutic test " will often render 
the diagnosis clear in the early stages of the condition. Healing 
occurs with scar-formation of a peculiar stellate appearance, and 
is usually high up in the larynx. The edema is not localized in 
syphilitic laryngitis, but is more general in character and causes 
dyspnea. In the tertiary stage there may be tendency to localiza- 
tion, due to syphilitic chondritis or perichondritis. 

Malignant Disease. — The age and history are important. The 
glandular involvement takes place late in laryngeal carcinoma. 
There is very little edema until the case has progressed beyond 
the stage in which diagnosis would be difficult. There is early 
alteration in the voice. There is always associated some catarrhal 
condition. Gradually, as the growth increases, the swelling and 
edema begin and ulceration takes place ; the odor is characteristic, 
and resembles that noted in paralysis. With the ulceration, hemor- 
rhage of an alarming nature takes place. The pain is pronounced, 
reflected, and sharp. 

Prognosis. — If seen early and before much structural alteration, 
with proper treatment many cases can be cured ; but if the structural 
alteration has taken place, permanent restoration of the voice can- 
not be accomplished. While the inflammatory symptoms may be 
entirely relieved, the voice cannot be restored to its proper quality. 

Treatment. — In all catarrhal conditions of the nose, naso- 
pharynx, and pharynx, with the constant accumulation and the 
irritation produced by such accumulation, there must necessarily be 
produced continued irritation of the laryngeal structure. Repeated 
and thorough cleansing of such affected parts should be strictly 
enforced. For its cleansing and detergent effect, bicarbonate of 
potassium and bicarbonate of sodium, of each 10 to 15 grains to 
the ounce of warm water, three or four times daily, as a douche or 
by means of a spray, should be used. 

For the treatment of the catarrhal condition after cleansing, there 
should be applied directly to the structures a mild astringent. 
For this purpose a solution of sulphate of copper or nitrate of sil- 
ver, 5 to 10 grains to the ounce, or, better, 3 per cent, chlorid of 



SIMPLE CHRONIC LARYNGITIS. 



683 



zinc may be employed, and intralaryngeal applications made. When 
applied 'by means of cotton or sponge, care should be taken that no 
excess of the solution be used, as the pressure employed in the 
application may cause the solution to run over healthy structures 
and down into the trachea. Equally good results will be obtained 
by the application, by means of a spray, of a 3 per cent, solution 
of alumnol ; although a comparatively new drug, I have found it 




Fig. 228— Ingals' laryngeal speculum. 

highly beneficial in such conditions. The employment of astrin- 
gents is often overdone, and applications should not be made 
oftener than every other day. 

Besides the correction of any nasal irregularities, attention must 
be given to the individual's personal habits as regards the use of 
tobacco and alcohol. As climate and occupation may have to do 
with the case as etiological factors, temporary or possibly perma- 
nent change from such exposure should be insisted upon. It must 
be remembered that the condition may be dependent upon or 
aggravated by gastro-intestinal, hepatic, and even renal lesions. 
In such cases treatment should be directed toward the offending 
organ. If the general health is at fault, constitutional treatment 
should be instituted. Of the therapeutic agents administered for 
the direct effect on the mucous membrane, if the secretions are 
profuse, yet tenacious, benzoate of sodium, three or four times daily 
in 5-grain doses, is highly beneficial. An admirable drug for this 
stage is hydra stin in 1- to 5-grain or the fluid extract in 5- to 30- 
drop doses, three or four times daily, or the compound mistura 
hydrastis (Llewellyn's) in teaspoonful doses in plenty of water after 
meals. If the secretions are scanty and there is a tendency to 
dryness of the membrane, iodin gr. -J-, phosphorus gr. T ^-, bromin 
gr. I-, in sherry wine (compound wine of iodin), with plenty of 
water three times daily is useful. 



684 DISEASES OF THE LAEYNX. 

FOLLICULAR LARYNGITIS. 

Synonyms. — Granular laryngitis ; Glandular laryngitis ; some- 
times called Clergymen's sore throat, but when so called it is 
associated with follicular pharyngitis. 

Definition. — An inflammatory process beginning usually in 
and involving primarily the entire mucous membrane, becoming 
localized in the small racemose gland-structure. However, the 
condition may be associated with follicular pharyngitis. From the 
inflammatory swelling there is retained secretion, giving rise to the 
minute elevations on the laryngeal surface. These retained secre- 
tions may escape by ulceration. 

Etiology. — Follicular laryngitis is rather a rare condition. 
The small mucous follicles, which are few in number, are largely 
located on the lateral and posterior surfaces of the laryngeal struct- 
ure. The involvement of these minute follicles is quite frequently 
associated with constitutional conditions, or follows fevers or 
wasting diseases in which there is perverted glandular secretion. 
It is also observed in speakers or individuals whose occupation 
necessitates the continued use of the voice, where the mucous 
membrane is liable to vascular engorgement, interfering tempo- 
rarily with the glandular secretion. The condition is also observed 
in individuals of a gouty or uric-acid tendency, the irritation of 
the surface-membrane, as well as the mucous membrane lining the 
secreting follicle, being due to the presence of uric acid in the 
blood. Follicular laryngitis is nearly always associated with the 
same condition in the pharynx. 

Pathology. — The pathological alterations are practically the 
same as in follicular pharyngitis, although in the pharynx the 
involvement is limited more to the actual gland-structure. There 
may be considerable alteration in the connective tissue of the sub- 
mucosa, but, as a rule, it is slight, if at all. 

Diagnosis. — The diagnosis can usually be made by aid of the 
laryngoscopic mirror. 

Prognosis. — The prognosis is good as to life, but/ a perma- 
nent cure may not be effected) unless the cause is removed before 
structural alteration of the tissue has taken place. 

Symptoms. — The symptoms are usually referable to the 
larynx. There is a peculiar sensation of tickling in the throat, 
causing a frequent desire to clear it, the effort giving only tempo- 
rary relief. When attended with cough it is of a voluntary 
character, unless complicated with inflammation of the bronchial 
tubes or trachea ; then it is more spasmodic and involuntary. 
Expectoration is usually scanty, appearing more like pellets of 
mucus. Frequently the cough is dry and there is little or no 
expectoration. Profuse expectoration would indicate associated 
inflammatory conditions. The alteration in the voice is not 



DRY LARYNGITIS. 685 

characteristic, but varies greatly in different persons ; there is 
slight hoarseness, which is due largely to the presence of tenacious 
mucus. Besides the accumulation of mucus about the vocal 
bands, the tone or character of the voice will be altered by the 
slight hyperemia or congestion occurring in the submucosa of the 
mucous membrane. In uncomplicated cases the symptoms are 
practically the same as in simple chronic laryngitis. 

Treatment. — In the treatment of follicular laryngitis it is of 
the utmost importance to ascertain, if possible, the underlying 
cause — whether it is due to occupation or is dependent upon 
some systemic condition. The internal medication should be 
directed toward the relief of any congestion, the re-establishment 
of circulation, and the use of such remedial agents as will stimu- 
late glandular secretion. Careful attention to the intestinal secre- 
tion, the use of salines, and the continued use of alkaline waters 
are highly beneficial. The internal administration of y^- grain of 
phosphorus, \ grain each of iodin and bromin in sherry wine, given 
three times daily in water, after meals, is an excellent tonic to 
glandular secretion. Small doses of the syrup of iodid of iron are 
equally beneficial. Local applications are of little, if any, value. 
However, the external application of cold-water cloths, followed 
by thorough drying of the skin by rubbing, may tend to promote 
the circulation and stimulate secretion. 

DRY LARYNGITIS. 

Synonyms.— Laryngitis sicca ; Atrophic laryngitis ; Ozsena 
laryngis. 

Definition. — This is a condition of the larynx in which the 
secretion and exudation from the mucous membrane tend to lodge 
upon the surface and form crusts. 

Etiology. — Atrophic or dry laryngitis usually occurs along 
with a similar condition of the pharynx and possibly of the naso- 
pharynx and anterior nares ; in other words, a condition, either 
local or systemic, which would bring about a similar condition in 
the structure above, is responsible for the laryngeal lesion. How- 
ever, the lesion in the larynx does not occur so often as in the 
structures above. This may be explained by the fact that the 
blood-supply is different and that the larynx is better protected 
from irritating foreign material. The fact that the process involves 
the anterior nares, nasopharynx, pharynx, and larynx, one after 
the other, by no means proves that it spreads by continuity of tis- 
sue. In the majority of cases in which the spreading follows in 
the order given above, it can be explained from a circulatory or 
nutritive standpoint, or from a standpoint of external irritation, in 
which the change in the mucous-membrane structure nearest the 
orifice permits the irritating material to be carried farther and 



686 DISEASES OF THE LARYNX. 

farther back into the respiratory tract. Besides, the local change 
in circulation, brought about by the pathological alteration in the 
submucosa, would in a measure necessitate spreading of the process 
by continuity and contiguity of structure. Whatever is the cause, 
be it due to systemic lesion, in which there is interference with 
venous circulation, causing cyanotic congestion, or to an inflam- 
matory process arising from some local irritation, there is not only 
an alteration in the submucosa but an interference with glandular 
function, thereby producing perverted secretion, and this altered 
secretion varies with the degree of change in the mucous-membrane 
structure. Inhaling of overheated air or air charged with gases is 
an important etiological factor. 

Pathology. — The secretion which accumulates on the surface 
of the mucous membrane is made up of inspissated mucus, in 
which are retained leukocytes and desquamated epithelium. This 
exudate is altered in character, being deficient in serum and con- 
taining an excess of fibrin. The secretion may become infected 
with bacteria, especially the Bacillus foetidus, and give rise to 
offensive breath — the so-called laryngotracheal ozena. The crusts 
usually form below the vocal cords. In many cases, however, 
there is very little accumulation of crusts, the surface being simply 
glazed and dry. This is especially true when the condition is 
caused by some constitutional lesion to which the mucous-mem- 
brane alteration is secondary. True atrophy within the larynx is 
rather rare, the condition being more properly one of dry laryn- 
gitis, due to perverted secretion and interference with vascular 
supply, the structural alteration being less marked than in the 
varieties described under Nose and Pharynx. 

Symptoms. — The symptoms are markedly influenced by cli- 
matic change, temperature, and moisture. Again, the symptoms 
present during the day differ very much from those at night. 
During the sleeping hours, while the patient is in the recumbent 
position, there is a greater tendency for accumulation of mucus 
and crust-formation, and the patient is likely to be weakened by 
distressing cough caused by the laryngeal irritation. There may 
be some difficulty in breathing, with considerable alteration in the 
voice. The irritation produced by the accumulated material with- 
in the larynx brings about violent coughing, in which the indi- 
vidual is able to free the structure of the accumulated masses, 
obtaining partial relief. In the variety in which there is little 
tendency to crust-formation, where the secretions are deficient and 
the membrane is dry and glazed, this difference in symptoms does 
not occur. The cough, however, is aggravatingly continuous, with 
a sudden altered tone and with practically no interference in 
respiration. The accumulated material when expelled closely 
resembles that seen in atrophic pharyngitis or rhinitis. # When the 
cough is of a violent nature, the expectorated material may be 



DRY LARYNGITIS. 687 

slightly blood-stained, owing to capillary hemorrhage. The appear- 
ance of this blood-stained secretion is often alarming to the patient. 

Diagnosis. — The subjective symptoms, in addition to the 
laryngeal examination, will render diagnosis easy. The thin, accu- 
mulated crusts beneath the vocal bands or adherent to the ventric- 
ular bands or arytenoid structure might be mistaken for ulcera- 
tion. Although the entire laryngeal structure may be involved, 
the process is usually subglottic, with concurrent glandular atrophy. 

Prognosis. — The prognosis is not uniformly good, but will 
depend entirely upon the amount of alteration of the mucous mem- 
brane and the amount of glandular atrophy which has taken place, 
or upon the permanent alteration of secretion dependent upon con- 
stitutional diatheses. The condition is always a chronic one, and 
from a curative standpoint the prognosis should be very guarded. 

Treatment. — The treatment should be directed toward the 
correction of any constitutional diathesis, with internal medication 
specially directed toward increasing glandular secretion. This 
can best be accomplished by the internal administration of 
phosphorus y^-g- grain, iodin -|- grain, bromin -1- grain in sherry 
wine, three times a day after meals. Equally good results may 
be obtained by the administration every three or four hours 
of 3- to 5-grain doses of terpin hydrate. If there is any con- 
joined bronchial irritation, 2- to 5-grain doses of carbonate of 
guaiacol should be administered. For its action on glandular 
secretion there should be administered, night and morning, table- 
spoonful doses of the granular effervescing phosphate of soda. 

Abnormalities in the nasal cavity and nasopharynx should be cor- 
rected. For the relief of the irritation caused by the accumulated 
dried material within the laryngeal structures, direct medication is 
essential. There should be applied directly to the surface, by means 
of inhalations, sprays, or applicator, dissolving emollient solutions. 

As an aid to dissolve the secretions, inhaling the steam 
from boiling water to which has been added 1 to 3 grains of 
carbolic acid to the pint, is admirable. Five grains of sulpho- 
carbolate of zinc to the pint of water is equally beneficial. 
AVhere the irritation is marked, great relief can be obtained by 
inhaling the fumes of compound tincture of benzoin, 1 dram, 
and chloroform, 10 drops, on which is poured a pint of boiling 
water. The application of stimulating solutions directly to the 
larynx, after the removal of the inspissated material, is in many 
cases necessary. The irritation of the membrane by the intro- 
duction of the applicator will be productive of no harmful results ; 
in this condition a slight irritation is really beneficial. After the 
removal of the inspissated mucus the parts should be lubricated 
with a bland oily solution, such as liquid albolene or benzoinol, to 
which has been added 6 drops of the oil of sandal-wood to the 
ounce. This solution, applied at intervals of three or four hours, 
will relieve the patient of the distressing symptoms produced by 



688 DISEASES OF THE LARYNX. 

the drying of the secretion. For its stimulating action there 
should be applied, with the aid of the laryngeal mirror, directly 
to the laryngeal structure, a 1 to 3 per cent, solution of chlorid of 
zinc. This should be done quickly after the patient has taken a 
full inspiration. Highly satisfactory results can be obtained by 
the local application externally of petroleum. This should be 
rubbed in, and a saturated flannel cloth should be wrapped around 
the neck during the night. The benefit derived from such appli- 
cations will offset the disagreeable odor of the drug. 



CYANOTIC LARYNGITIS. 

Synonyms. — Symptomatic laryngitis; Chronic edema; Angio- 
neurotic edema. 

This condition has been fully described under Nasopharynx 
and Anterior Nares. The lesion of the laryngeal mucous mem- 
brane differs very little from that in the above-mentioned situa- 
tions, the structural alterations depending upon the condition 
which produces the cyanotic congestion ; however, tumors of the 
neck, by pressure, may produce the condition in the larynx. The 
same is true of aneurysm of the aorta, which, by its interference 
with the circulation, will produce cyanosis or chronic congestion 
of the laryngeal membrane. 

The symptoms are the same as those of chronic pharyngitis. 
This condition is practically the same as that described by Morell 
Mackenzie under the term phlebectasis laryngea, which is nothing 
more than a varicose condition of the veins of the epiglottis, ven- 
tricular bands, and arytenoids. 

The prognosis will depend entirely on the causal factor, and 
whether it be one amenable to treatment ; or if the continued press- 
ure and malnutrition brought about by the cyanotic congestion 
have lasted long enough to produce atrophic processes in the mucous- 
membrane structure, even with the removal of the exciting cause 
there will be left permanent alterations in the laryngeal membrane. 

Treatment. — Local treatment is practically of no, avail, and 
the systemic medication should be directed toward the relief of the 
underlying cause. 

HYPERPLASTIC LARYNGITIS. 

Synonyms. — Hypertrophic laryngitis; Hypertrophy of the 
laryngeal tissue. 

Hyperplastic laryngitis is a rare condition in which, from slight 
irritation, there may be brought about a proliferation of the fixed 
connective-tissue cells, which is not of inflammatory origin, or 
which, if so, never goes on to the stage of complete organization 
and contraction. There is permanent thickening of the tissue, 
giving rise to some symptoms of obstruction and interference with 



ANEMIA OF THE LARYNX. 689 

mobility of the larynx. The tissue-change is identical with that 
in other structures, especially the so-called hypertrophy of the 
liver, in which there is overgrowth, but no tendency to contrac- 
tion. The cause is indefinite. Rarely does the hyperplastic 
change observed in tertiary syphilis involve the laryngeal struc- 
tures. However, this is possible, and the hyperplastic tissue may 
be dependent entirely upon this lesion (see p. 592). 

No treatment is productive of beneficial results unless there 
is removal of the tissue, which is not advisable, as it leaves scar- 
formation. 

SCLEROMA OF THE LARYNX. 

Synonym. — Chorditis vocalis inferior. 

Scleroma is a rare disease, supposed to be of bacterial origin, and 
consists of indurated areas involving the nose, nasopharynx, phar- 
ynx, and larynx. When occurring in the larynx it is usually be- 
neath the vocal cords and occasionally unilateral. AYhile supposed 
to be of bacterial origin, there is no definite clinical proof that it 
is either contagious or infectious. Some authors are inclined to 
the belief that it is a form of rhinoscleroma. The condition is 
scarcely analogous to rhinoscleroma of the nose. These consist of 
localized sclerotic spots or hyperplasias involving the mucous 
membrane of the upper respiratory tract. There may be diffuse 
infiltrations or merely small nodules. Instead of having the 
appearance of growing from the surface, they seem to have 
their origin underneath and give the impression of a submucous 
infiltration. There is an increase in the connective-tissue ronnd 
cells, a sort of embryonic cell proliferation, with organization 
and connective-tissue fibers forming through the mass. 

The local symptoms are largely catarrhal, and if occurring in 
the pharynx or larynx there is always associated cough. If the 
tumefaction increases and the lesion is located within the larynx, 
alarming symptoms due to stenosis may occur. The disease is of 
long duration and may end in ulceration and necrosis. 

Treatment. — Local treatment seems to be of little avail. 
However, some benefit has been derived by the use of the 
Roentgen ray. Some cases have been reported in which the 
patient was much benefited by endolaryngeal curetment. Person- 
ally I believe that it is practically an incurable affection . A 
study of the literature fails to show any authenticated cases of 
complete recovery. While the contagious or infections nature of 
the disease has not been fully established, the safest plan of pro- 
cedure is to observe all antiseptic precautions to prevent the 
spread of the disease. 

ANEMIA OF THE LARYNX. 

Anemia of the larynx is merely a local manifestation of a con- 
stitutional diathesis. There is not only deficient blood-supply, 

44 



690 DISEASES OF THE LARYNX. 

but deficient vascular tone. Besides the relaxed vessel, the entire 
tissue will be loose and boggy. There is a tendency to venous 
stasis and leakage from the relaxed vessels, giving rise to slight 
bogginess of the tissues. It may be sufficient to cause alteration 
in the voice, especially in tone and force ; besides, the edema may 
be sufficient to interfere with vocalization. Structural alteration 
in the tissue is very slight unless concurrent with some other 
lesion. 

The diagnosis, prognosis, and treatment will depend entirely 
upon the cause of the anemia. 

Local treatment is not productive of permanent results, afford- 
ing only temporary relief. The treatment should be directed toward 
the underlying cause. 

HYPEREMIA OF THE LARYNX. 

Hyperemia not connected with any inflammatory lesion occurs 
in individuals who are subjected to conditions which produce 
sufficient irritation to cause localized increase in the blood- 
supply, and yet not sufficient to bring about actual inflammatory 
phenomena. The same may be said of plethoric individuals or 
of persons who are continuously using the voice, or whose occupa- 
tion subjects them to the slight but continual irritation from dust 
or irritating fumes. Persons who habitually use tobacco or alcohol 
also exhibit a somew T hat similar condition. 

Pathology. — The hyperemia may be irregularly distributed 
in the laryngeal structure, both supra- and sub-glottic. There is 
practically no structural change, except that from the hypernutri- 
tion there may be overproduction of the connective or epithelial 
elements. In the plethoric condition, where, from overstimula- 
tion of the already hyperemic vessels, slight hemorrhage may 
occur, as referred to in Hemorrhage of the Larynx, the voice is 
usually altered in character, being somewhat irregular and imper- 
fect in tone. There is a constant tendency to clear the throat, and 
there may be some hypersecretion. No pain is felt unless asso- 
ciated with some other condition. 

Treatment. — The treatment should be directed toward the 
relief of any condition which causes the local hyperemia. A 
change of occupation, together with the removal of any stimulant, 
should be insisted upon, if such is known to be the exciting cause. 
The treatment is not local, but should be directed toward the 
systemic condition. 

PEMPHIGUS OF THE LARYNX. 

This is a rare, peculiar, inflammatory condition in which there 
is an eruption of vesicles resembling very much those seen on the 
skin in cases of herpes. The vesicle may form anywhere in the 



SINGERS' NODULES. 691 

laryngeal structure, but is usually found on the ventricular bands 
and arytenoid surfaces, although they may be below the vocal 
bands. " The formation of the vesicle is ushered in by slight sys- 
temic symptoms, such as rigor and slight rise in temperature. 
There is soreness of the throat, with slight alteration in the voice, 
and sharp, cutting pains, especially on swallowing, while inspec- 
tion will show a similar condition on the pharyngeal structures — 
in fact, on any of the faucial mucous-membrane surfaces. There 
may be slight edema surrounding the vesicle. The condition com- 
monly exists along with gastro-intestinal lesions, or follows long- 
protracted illness or suppurative processes. The vesicle usually 
ruptures in a few hours, and leaves a minute superficial ulcer. 

Treatment. — The treatment should consist in the correction 
of any intestinal irregularities, followed by drugs to stimulate the 
normal secretion, such as the granular effervescing phosphate of 
sodium or succinate of sodium. Antiseptic, cleansing mouth- 
washes should be used, such as boric acid, 10 grains to the ounce, 
either alone or combined with 3 to 5 drops of carbolic acid. 

SINGERS' NODULES. 

Synonyms. — Chorditis tuberosa; Trachoma of the vocal 
cords; Pachydermia laryngis ; Trachoma; Chorditis nodosa; Vocal 
nodules ; Trachoma of the larynx. 

Definition. — A new growth, the result of inflammatory action, 
situated within the vocal cord, involving its margin, and usually 
located near the junction of the anterior and middle thirds. It 
consists of a small ovoid nodule situated on the edge of one or 
both vocal cords, and may be opposite or located at different 
points. It may be single or multiple, and may develop on both 
cords simultaneously, or merely on one, followed later by the same 
condition on the other cord. 

Etiology. — This nodular affection of the cord is not only an 
inflammatory process, but the result of inflammatory organization, 
and the interference with phonation continues after the subsidence 
of the inflammatory action. The most common cause of the con- 
dition is generally believed to be improper methods of producing 
tone, as well as too frequent and forcible use of certain tones, in 
which the same intrinsic and extrinsic muscles are brought into 
play and the vocal cords kept practically in the same position. 
This is especially true in certain registers, more commonly in the 
medium or upper medium register. While the condition is most 
likely to occur in singers or persons who constantly use the voice, 
yet causal factors are by no means thus limited. It is not neces- 
sarily due to improper or extreme use of the cords, but may be the 
result of using the voice when the surrounding tissue of the cords 
is congested from direct or associated laryngeal inflammation, or 
from the forcible or sudden use of the voice when the parts are 



692 DISEASES OF THE LARYNX. 

hyperemic from violent exercise. While some cases may be caused 
by chronic laryngitis or attended by it, yet in the majority of cases 
the inflammatory action involving the laryngeal structure seems to 
be secondary to the nodule. I have observed a number of cases of 
involvement of the larynx and cords during and following an 
attack of la grippe, in which I believe the nodular formation (Fig. 
229) was due to localized hemorrhagic areas, with localized spots of 
inflammation and organization. In many cases not of inflammatory 
origin, but where sudden or improper stress had been thrown upon 
the vocal cords, I believe this hemorrhagic condition explains the 
process. The fact that a nodule may appear suddenly, regardless 
of cause, bears out the hemorrhagic theory. People of a tubercular 
family history or a tubercular tendency seem to be predisposed. 
However, any condition in which the vascular tone was not up to 
par would be an equally predisposing factor. I have observed 
this same nodular condition of the cord in individuals who were 
in the habit of using the long-distance telephone at frequent inter- 
vals and continuing the conversation a considerable length of 
time. The added stress on the vocal cords had brought about 
a condition exactly the same as in Singer's nodules. 

Pathology. — The pathological alteration within the tissue 
seems to be, as has been shown by Kanthack, largely that result- 
ing from inflammatory change. The different appearances observed 
by microscopical examination are only the different stages of the 
inflammatory condition, with its subsequent fibroid changes. That 
the nodule is of inflammatory origin is proved by the fact that 
there is no tendency to increase in size. Tumors and hyperplasias 
show this tendency. Frankel and others believe the nodules to be 
of glandular origin. This, however, I do not consider correct, 
on account of the absence of gland-element in the cord-structure, 

and when the glandular element is found 
present, it is more indicative of a benign 
tumor. The epithelial layer will be 
thickened, and even papillary prolonga- 
tions be formed, very much resembling 
papilloma. The whole cord may be in- 
volved with minute granulations, the 
thickening being more within the cord 
than on the surface. However, owing 
to the nodules the edge of the cord is 
uneven, and the nodular thickening pre- 
fig. 229. -showing nodular in- vents perfect approximation (Fig. 229). 
Swfng^grfp^e 6 '^ ^ 1 C ° rdS fol ~ Tnis condition may be due to hemor- 
rhage. In certain inflammatory lesions, 
especially la grippe, there seems to be poured out into the tissue a 
material which remains quite similar to an amyloid infiltration. 
This tends to render the structure irregular and nodular. Such a 
condition is chown in Fig. 229. 




SIXGERS' XOJDULES. 693 

Where the nodule is on the surface, its structure and inter- 
ference with approximation of the cords are very much the same 
as the condition in the heart-valve where papillary organization 
occurs as a result of endocarditis. 

Symptoms. — The symptoms, which are largely those of 
alteration in voice, vary in accordance with the stage and degree 
of involvement of the cords. The alteration in tone will vary 
from slight hoarseness to complete loss of voice. The pitch is 
altered and the tone irregular and uncertain. The patient is appre- 
hensive and nervous, which adds to the irregularity and uncertainty 
of the voice. Where there is complete loss of the voice, there is 
usually associated some paresis of the tensor muscles, as well as 
catarrhal laryngitis ; this, however, may be the result of inflam- 
matory action produced by thickening of the nodule upon the oppo- 
site cord. The alteration in the voice will become more marked as 
the nodule becomes more fibrous and involves in its contraction 
surrounding structure. By the aid of the laryngoscope the nodule 
can be seen reddish in the early stage and, later, whitish or gray- 
ish-white in appearance, varying in size — sometimes no larger than 
a millet seed. Where the nodule is single, there may be a cor- 
responding depression on the opposite cord. Where multiple and 
unilateral, the cord will present a peculiar zigzag appearance. 

Diagnosis. — The history of the case, the location of the 
nodule, and the accompanying symptoms render the diagnosis 
easy. However, the possibility of incipient malignant growth 
should always be remembered. 

Prognosis. — If single, and the condition is not too far 
advanced in fibrous-tissue contraction, the prognosis is fairly 
favorable. However, if of long duration, with the formation of 
fibrous tissue, the prognosis as to recovery of voice is bad. As 
far as the general health is concerned, the prognosis, of course, 
will be good. 

Treatment. — It has been shown that much can be done for 
the relief of this condition by the proper exercise of the intrin- 
sic and extrinsic muscles of the larynx, more especially the in- 
trinsic. The surgical treatment varies with the size and location 
of the nodule, as well as whether it is multiple or single, sessile 
or pedunculated. If the tumor is pedunculated, which is rarely 
ever the case, its removal can easily be accomplished by means 
of the laryngeal cutting-forceps, shown in Figs. 230, 231. The 
best plan of treatment, and the one that should be carried out first 
of all, is following the old surgical law of putting the part at 
rest, and the patient should be forbidden to use his voice even 
in a whisper, the vocal cords being allowed to rest for days at a 
time. I have had some excellent results in following this method, 
even to the point of keeping the patient in bed. However, 
if fibrous tissue has already formed, then the treatment by rest 



694 



DISEASES OF THE LARYNX. 



will not remove the entire nodule. In 
gymnastics also produce excellent results. 



this condition vocal 
If the nodule is dis- 




Fig. 230. -Mackenzie's throat forceps opening laterally, with serrated jaws. 



tinctly sessile, the advisability of surgical interference is question- 
able, owing to the danger of further and permanent injury to 
the vocal cords. Local applications are advised by such authori- 




Fig. 231.— Mackenzie's laryngeal anteroposterior forceps. 

ties as Mackenzie, Bosworth, Schrotter, McBride, and others. For 
such local applications the solutions giving the best results are the 
3 per cent, solution of chlorid of zinc, or perichlorid of iron of the 
strength of 1 dram to the fluidounce. Early in the nodular for- 
mation, good results may be obtained by crushing or squeezing the 
nodule by means of dull forceps. 



CHRONIC INFLAMMATIONS OF THE LARYNX. 

SYPHILIS OF THE LARYNX. 

Synonyms. — Specific laryngitis ; Laryngitis specifica. 

Definition. — A specific inflammatory condition of the larynx 
occurring as part of the systemic exhibition of syphilitic infection. 
It presents secondary and tertiary lesions analogous to the second- 
ary and tertiary lesions observed elsewhere, the primary lesion in 
this location being practically unknown. In the secondary stages 
the laryngeal involvement is characterized by erythema, superficial 
ulceration, mucous patches, and small condylomata. The tertiary 
stage is distinguished by formation of gummata, deep and destruc- 
tive ulceration, and subsequent cicatrization. It may be hereditary 



SYPHILIS OF THE LARYNX. 695 

or acquired, and may occur at any age, though some periods are 
more prolific than others. 

Etiology. — Primary laryngeal infection is a condition prac- 
tically unknown, though the possibility of its occurrence is, of 
course, to be considered. Laryngeal syphilis is usually part of 
the manifold exhibitions which the disease offers in the human 
economy. Both secondary and tertiary lesions occur in individ- 
uals who have acquired the disease through personal inoculation ; 
but the laryngitis of hereditary syphilis is almost exclusively of 
the tertiary type. Of the two types the tertiary more often 
occurs, and it may appear a great many years after the existence 
of the primary lesion. Males are more frequently affected than 
females, and there are more cases reported in the winter months 
than in the summer. No age is exempt from its occurrence. 
Pathology. — The inflammatory phenomena have been already 
described at length on pages 146 to 149. 

To this article the reader is referred to avoid unnecessary repe- 
tition, as histologically the structures and processes in the larynx, 
save as they differ, from the contour of the region, are not different 
from those occurring in the mucous membranes and their support- 
ing structures elsewhere. 

Symptoms. — Here, as in laryngeal tuberculosis, the attempt 
to describe symptoms commonly pathognomonic of the condition 
is rendered difficult by the very great variety, both of degree and 
kind, in different cases. No fixed list of general symptoms can 
be given as an infallible guide to diagnosis for each case that 
comes to the practitioner. In the majority of cases the subjective 
annoyances are slight, and the whole laryngeal trouble is regarded 
as nothing more than a slight cold in the throat. On the contrary, 
the most severe pain and suffering may result, and between these 
two extremes there is a wide range of variations, not in the least 
relieved by the facts that secondary syphilis may be of tardy devel- 
opment, the tertiary variety appear early, or both apparently coin- 
cide. Primary lesion of the larynx is so rare as to make its con- 
sideration useless. The secondary lesions are worthy of careful 
attention. The general symptoms of the affection are similar in 
both the secondary and the tertiary type, but they differ in degree. 
Prominent among these stands alteration in the' character of the 
voice, which comes to have a strange, indescribable, yet character- 
istic quality. Sound-production may be difficult or painful, and 
occasionally total aphonia is observed. Paralysis of the vocal 
cords, usually unilateral, is at times observed early, and cough is 
in many cases an annoying symptom — short, hacking, and exhibit- 
ing the signs of an irritative cause. Expectoration varies from the 
ejection of a thin, serous secretion, arising from a simple catarrhal- 
like inflammation of the laryngeal membrane, through all the 
variations of stringy, tenacious mucus, up to the offensive necrotic 



696 DISEASES OF THE LARYNX. 

discharge of the later stages. The amount from the larynx itself is 
small, and is observed better in situ by the laryngoscope. Pain is 
a variable symptom, and its occurrence and degree depend upon 
the extent of ulceration and the irritation of abraded areas. Rarely 
does it happen otherwise, and its severity is not nearly so keen as 
is observed in tubercular laryngitis. Dysphagia may exist in some 
degree, and because of ulcerative action and dyspnea in the later 
stages of gummata or of cicatricial contraction, it may become an 
urgent symptom. Local pain and tenderness, especially in late 
cases, may be well marked. Hemorrhage is rare, yet cases of 
sudden and profuse loss of blood from erosion of an artery have 
been recorded. Secondary syphilis of the larynx commonly pre- 
sents four well-defined lesions. These are the erythema, super- 
ficial ulceration, the mucous patch, and the condyloma. 

Erythema. — This may occur within a few weeks after the 
primary lesion, or more frequently in five or six months, and its 
occurrence is usually just after the dermal eruption — to which it 
is analogous — has subsided. Inspection by the laryngoscope shows 
upon some portions, or the whole, of the posterior surface of the 
epiglottis, the aryepiglottic folds, the false cords, and sometimes 
the vocal cords themselves, an inflammatory turgescence. This 
may be a uniform congestion and simulate entirely — a simulation 
borne out, it may be, by the objective symptoms — a simple 
catarrhal process ; or in a typical case there is irregularity in alter- 
nation of dark and light areas, giving a pathognomonic, mottled 
appearance to the affected membrane. Infiltration and swelling of 
the vocal cords may be seen. Subjectively the symptoms are not 
severe. Pain is absent, deglutition is naturally performed, and 
cough may be slight. Hoarseness, or even total aphonia, may 
ensue upon the inflammatory swelling of the phonatory elements. 
If not treated, the duration is variable, and the ready amenability 
to antisyphilitic measures furnishes a means of diagnosis prompt 
and certain. The existence of the lesion is not always to be 
regarded as a forerunner of more severe manifestations. 

The Superficial Ulcer. — This lesion occurs in practically the 
same sites as the erythema, and is the result of a necrosis of the 
syphilitic inflammatory infiltrate in the superficial layers of the 
membrane, or as the result of the disintegration of a mucous 
patch. The shape of the ulcer is irregularly rounded ; there is an 
inflammatory areola surrounding it, and the shallow floor is seen 
covered with a yellowish, blood-tinged material, containing, it may 
be, some few bits of necrosed tissue. The process is a slow one, 
and as one ulcer heals there may be the formation of others else- 
where, possessing the same characteristics. It is to this tendency 
to recurrent ulceration that the name of recurrent ulcerative laryn- 
gitis owes its origin. Upon the vocal cords the process is so 
minute, because of the scanty membranous investment, as to need 



SYPHILIS OF THE LARYNX. 697 

careful observation for its detection. Healing usually takes place 
with the formation of a superficial, yellowish, stellate scar. Symp- 
toms of ulceration are not intrinsically severe. Pain is generally 
slight, and is proportionate to the amount of ulceration ; the same 
is true of the irritation of ulcerated areas in swallowing and speak- 
ing, as also are cough and voice-impairment. Expectoration is at 
a minimum. The process is, as a rule, not seen until from two to 
seven years after the primary lesion. 

The Mucous Patch. — The existence of mucous patches upon 
the laryngeal surface is said by many observers not to occur ; but 
though infrequent, is undoubtedly to be observed at times. When 
so occurring they may be coexistent with the same lesion of the 
tongue or pharynx, or occur independently. The usual locations 
are the upper surface and free margins of the epiglottis, the ary- 
tenoid structures, and the vocal bands. They are never observed 
below the true vocal cords. In shape they are of regularly rounded 
outline, the margins being slightly elevated ; the surrounding tis- 
sue is inflamed into an angry areola, and the surface of the patch 
is whitish or covered with a yellowish, pultaceous mass, which may 
be someAvhat blood-tinged. The floor of the patch may be the 
seat of rapid and persistent granulations, which tend to repro- 
duction, if removed. The patches themselves may be painful to 
the touch of the probe, and are usually resistant to treatment. 
They may be single or occur in multiple groups, and healing is 
commonly followed by a well-marked cicatrix. The virulent and 
dangerous character of the secretion of a mucous patch is to be borne 
in mind. Recurrence of the lesion is not unlikely. 

Condylomata. — These occur in some cases as small, yellowish 
pimples, having an elevated base. They rarely cause annoyance, 
and usually disappear spontaneously. 

The Tertiary Manifestations. — The tertiary type is that of 
hereditary syphilis. If not so occurring, however, it usually 
begins some five or six years or later after the primary sore. 

The Gumma. — This occurs usually in the epiglottis, upon the 
arytenoids, or in the interarytenoid commissure, though it may take 
place in any part of the larynx. The process may be limited to a 
single lesion or it may be multiple. Gummata first appear in the 
deeper layers of the membrane, and present the appearance of 
small, smoothly rounded protuberances, not differing in hue from 
the adjacent membrane, and increasing slowly in size. At their full 
size they vary from that of a pin-head to a small marble, and their 
existence is commonly not preceded by inflammatory symptoms, 
but is sudden in origin. After they attain their full size, softening 
of the mass takes place, a yellow spot appears in the center, rupt- 
ure of the overlying tissue and discharge of the softened material 
occur, with formation of a deep and destructive ulcer. The process 



698 DISEASES OF THE LARYNX. 

is generally rapid, but cases in which breaking down of the gumma 
is long delayed, or even sometimes totally absent, may be occa- 
sionally observed. The presence of gummata is attended by symp- 
toms proportionate to their size and location. Pain, if present, is 
generally the dull, deep-seated aching of nerve-pressure. Local 
tenderness may be elicited. There may be some discomfort in 
deglutition, and phonation may be impaired. Cough is not usual, 
but respiration may be embarrassed seriously by the swelling of 
the gummata, which occlude the air-passage, or by the inflam- 
matory edema.. Paralytic conditions may not uncommonly be 
observed, usually unilateral, and attended by a peculiar stridor 
of the voice in phonation. The hyperplasia of the connective 
tissue may occur in the larynx as well as in the other portions 
of the upper respiratory tract (see page 592). This in the larynx 



Fig. 232.— Specific tumor below the vocal cord and involving the cord (see page 592). 

may occur in the form of excrescences or hyperplasias or in the 
form of a tumor, as shown in Fig. 232, which, in all probabil- 
ity, was nothing more than a beginning gummatous formation and 
which was arrested before the breaking-down process bad 
occurred. The tumor, shown in Fig. 232, entirely disappeared 
under specific treatment. In appearance the mass resembled very 
much a malignant growth. 

The Tertiary Ulceration. — As already mentioned, this occurs as 
a sequel of gummatous degeneration, and is one of the most severe 
and destructive of the syphilitic lesions. Following the rupture of 
the gummatous mass, there is left at its site a deep, foul, and 
rapidly spreading ulcer. This, of course, occupies the region of 
the original gumma, is more frequently seen on the free margins 
of the epiglottis, and is not rarely symmetrical. The ulcers are 
deeply placed, the edges ragged, shreddy, and sharply defined ; the 



SYPHILIS OF THE LARYNX. 699 

pit of the ulcer is filled with a foul-smelling, nasty, greenish or yel- 
lowish mass of purulent, tenacious, necrotic tissue, and the adjacent 
membrane shows a deeply inflamed, elevated zone immediately sur- 
rounding it. The spread is rapid, both in extent and depth, and 
coalescence of adjacent ulcerative processes is observed. Later, 
the perichondrium is attacked, and ulceration and necrosis of the 
laryngeal cartilages occur, with a permanent loss of more or less 
of these structural elements. No position of the larynx is exempt 
from the process or its spread, and the ensuing condition is both 
pitiable and dangerous in the extreme. The epiglottis is often 
totally destroyed ; the arytenoids also and the cricoid cartilage 
may undergo necrosis, with sloughing or the formation of retained 
sequestra. The involvement of the thyroid is, as a rule, confined 
to the very latest stages of the disease. During the progress of 
tertiary ulceration the condition of the patient is pitiable in the 
extreme. Pain may be severe and constant, dull and deep-seated. 
Deglutition is attended possibly with severe pain. Dyspnea may 
be urgent and alarming. 

Dysphoria or even aphonia is frequently observed, or, at the 
least, a marked alteration in the voice. The expectoration is of a 
mucopurulent character, mixed with dark, ill-smelling bits of 
necrosed tissue, and is sometimes blood-stained. Hemorrhage is, 
however, rare. Bits of the eroded framework of the larynx may be 
expectorated or swallowed, and one case of fatal asphyxia is recorded 
from impaction of a loosened and necrotic arytenoid in a stenotic 
windpipe. In the later stages, not only dysphagia may be present, 
but the attempt to take food may be embarrassed by the passing of 
solid bits, or even of fluids through the exposed glottis, followed 
by paroxysmal choking and strangling. Tenderness and pain, 
especially after the involvement of the perichondrium, may be 
very severe. There may be marked external swelling. Not rarely 
among the ulcerative phenomena is a tendency to recurrent exhi- 
bitions or outbreaks following quiescent intervals. 

Cicatrization. — Following the ulcerative process of the tertiary 
stage, nature attempts a rapid cicatrization of the necrotic areas, 
and, as usual, this is attended by contraction and the formation of 
dangerous stenoses. These cause in the larynx marked alterations 
in the contour of the structure, and lead to permanent change in 
the performance of its function. The subjective symptoms of the 
ulcerative stage are all intensified, and there arises the danger of 
asphyxia from the progressive narrowing of the air-passage. Such 
a stricture is more common after successive attacks of ulceration 
than after a single occurrence. The voice is permanently im- 
paired, and acquires the almost pathognomonic characteristics in a 
marked degree, and all of the symptoms may be aggravated by 
the subacute or chronic catarrhal inflammation of the membrane 
not showing other specific appearances. 



700 DISEASES OF THE LARYNX. 

Diagnosis. — The direct diagnosis is to be based on (1) the 
personal and hereditary history of the case ; (2) the consideration 
of the general symptoms and condition of the patient; (3) the 
result of antisyphilitic therapeusis ; (4) the local symptoms, 
and (5) the Wassermann reaction (see page 152). With such 
means of identification a direct diagnosis should be made 
without difficulty. In making a differential diagnosis the pos- 
sible existence of a double lesion, especially with tubercular 
laryngitis or carcinoma (see table, page 708), is to be kept in 
mind. Tubercular laryngitis has a pale membrane and more 
shallow ulceration, without inflammatory areola ; more pain and 
less healing tendency are exhibited, and its pulmonary lesion is a 
valuable diagnostic medium, unless mixed infection exists. The 
therapeutic test is of great value. Carcinoma before ulceration is 
a distinct, well-defined, and not distorting tumor, and its pain is, 
after ulceration, sharp and lancinating. Lupus does not ulcerate 
so freely, if at all, and cicatrization is by no means marked. Here 
the clinical history is valuable. My clinical experience has been 
that where there is any latent specific granulomata, especially of 
tubercular or specific type, where the infection has been mild and 
where the power of resistance has been equal to or able to over- 
come the invasion, that where the individual has suffered from an 
attack of epidemic influenza, it is most likely to light up this 
underlying specific process. This is especially true in latent syph- 
ilitic cases, and in a number of instances I have observed in the 
larynx, in the vestibule of the larynx, about the vocal cords, at 
the base of the tongue, especially in the region of the lingual 
tonsil, syphilitic granulomata or syphilitic gumma, which in many 
instances have been confused with malignant growths. They 
differ in this particular : That, in following influenza, the rapid- 
ity of the growth is much in excess of the malignant type. There 
is an early involvement of the glands, a lack of pain, and difficulty 
in swallowing, lack of cachexia on the part of the individual ; 
that, owing to the sudden lighting up of the growth, there is a 
tendency to hemorrhage early, which is not the case in malignant 
growth. In other words, the whole condition is fulminating with- 
out the secondary malignant symptoms or characteristics. I have 
observed in the last few years a number of these cases that had 
been pronounced malignant carcinoma on a hasty examination, 
when under specific treatment the tumor had entirely disappeared ; 
and I certainly urge, not only on the part of the specialist, but for 
any one interested in this line of work, that extreme conserva- 
tism be employed in all cases of laryngeal growth, and that the 
therapeutic test be first applied before pronouncing the case 
malignant. 

Prognosis. — As a rule, the outlook is favorable to life, 
though the process may cover some time. The disease can usually 



SYPHILIS OF THE LARYNX. 701 

be halted by proper antisyphilitic treatment, though irretrievable 
loss of tissue in the later stages leads to serious impairment of 
function. The secondary phases offer better opportunities for suc- 
cessful medical procedure ; while in the later tertiary stages sur- 
gical measures may need to be invoked. The danger to life is 
largely that of suffocation from inflammatory edema or stenosis. 

Treatment. — In the superficial ulcer the parts should be 
thoroughly cleansed, following the same method as given under 
Tuberculous Lesion of the Larynx, and then touched with 20 to 
40 grains of nitrate of silver to the ounce of water. Good results 
may be obtained, when the ulcer is accompanied by an acute 
inflammatory process involving the surrounding tissue, by insuffla- 
tion, after thorough cleansing, of pyoktanin (1 to 2 drams to the 
ounce of stearate of zinc). The objection to the use of powders 
is the danger of drawing the powder farther into the respiratory 
tract and producing irritation. This can be obviated by the 
patient taking a deep inspiration and holding the breath during 
the insufflation. By so doing, the first respiratory act after the 
application will be one of expiration. For relief of the pain, 
insufflations of orthoform are highly beneficial. 

In the deep ulceration due to gummatous degeneration the 
same course of local procedure as is followed in the secondary 
lesions should be observed. In the secondary and tertiary stages, 
while the local treatment is of importance, yet the internal medi- 
cation is the prime factor, and the system must be brought as soon 
as possible completely under antisyphilitic influence. 

The systemic plan of treatment of syphilis in the secondary 
and tertiary stages as given below is practically the same as given 
m text-books of surgery and medicine, and is really the method fol- 
lowed by Gross, Keen, and White, as given by J. Chalmers DaCosta. 

Secondary Stage. — In the secondary stage the aim is to cure 
the disease. That it can be cured is known from the fact that 
reinfection occurs in some persons. The old axiom, " Syphilis once, 
syphilis ever," is not true. Mercury must be used, the form 
being a matter of choice. Fournier first advocated intermittent 
treatment. In this plan give gr. ^ of protiodid of mercury daily 
for six months, then stop a month ; then give mercury for three 
months, then stop two months. During the first year the patient 
is under treatment nine months, and during the second year eight 
months. Some prefer the intermittent and others the continuous 
plan. AVhite greatly prefers the continuous plan. The rule in 
most cases is to give mercury for two years. Find the patient's 
dose of tolerance, and keep him on this amount. Gross's rule for 
continuous treatment was to order pills of the green iodid of mer- 
cury, each pill containing gr. 4-. The patient was ordered one 
pill after each meal to begin with ; the next day he took two pills 



702 DISEASES OF THE LARYNX. 

after breakfast ; the following day, two after dinner, and so on, 
adding one pill every day. This advance was continued until 
there was slight diarrhea, griping, a metallic taste, or tenderness 
on snapping the teeth together, whereupon one pill was taken off 
each day until the unfavorable symptoms disappeared. This 
experimentation gives a dose on which the patient can be kept 
with entire safety for a long time ; but if it is found that colic or 
diarrhea is apt to recur, there must be added to each pill gr. y 1 ^ of 
opium. The patient is given mercury in this way for two years. 
Every time new symptoms appear the dose is raised, and as soon 
as they disappear, it is lowered to the standard. If the protiodid 
is not tolerated, give the bichlorid : 

1^. Hydrargyri chloridi corrosivi, gr. iss (0.1) ; 

Syrupi sarsaparillse compositi, fl^iv (120.). — M. 
Sig. — One teaspoonful in water after meals. 

Tertiary Stage. — If at any time during the case tertiary 
symptoms appear, the patient should be put on mixed treatment. 
In any case, after two years of mercury, add iodid of potassium to 
the treatment. White's rule is to use this mixed treatment for at 
least six months (if any symptoms appear), the six months' course 
dating from their disappearance. This emphasizes the fact that 
the iodids alone will not cure tertiary syphilis. In obstinate ter- 
tiaries or in nervous syphilis the iodids should be run up to an 
enormous amount (from 30 to 250 grains per day). An easy way 
to give iodid is to order a saturated solution, each drop of which 
equals 1 grain of the drug. Each dose of the iodid is given one 
hour after meals, and in at least half a glass of water. If the iodid 
disagrees, it may be given in water containing 1 dram of aromatic 
spirits of ammonia, or in milk. Iodid of sodium may be tolerated 
better than the potassium salt, or the iodids of sodium, potassium, 
and ammonium may be combined. In giving the iodids begin 
with a small dose. During a course of iodid always give tonics 
and insist on plenty of fresh air. Arsenic tends to prevent skin- 
eruptions. The iodids, when they disagree, produce iodism — a 
condition which is first made manifest by running of the nose and 
the eyes. In some subjects there is an outbreak of acne, vesicular 
eruptions, or even bullaa or hemorrhages. Iodism calls for a reduc- 
tion in dosage, and if severe or persistent, for the abandonment of 
the drug. After the patient has been for six months under mixed 
treatment without a symptom, stop all treatment and await devel- 
opments. If during one year no symptoms recur, the patient is 
probably cured ; if symptoms do recur, there must be six months 
more of treatment and another year of watching. 

The injection of gray oil, beginning with 1 drop and gradually 
pushing up the solution until 6 or 8 drops has been reached, 



TUBERCULOSIS OF THE LARYNX. 703 

followed by interruption with mixed or iodid-of-potassuim treat- 
ment for ten days to two weeks, is admirable in the tertiary stage. 
This is highly recommended by J. Solis Cohen. This plan of 
treatment is highly beneficial in the tertiary stage, especially if the 
cartilage is involved — a chondritis or perichondritis ; however, in 
cases in which there is marked inflammatory edema, when iodid 
of potassium is administered care must be exercised, as the dose is 
increased, that the original edema is not aggravated by iodism.^ ^ 

Much has been written in regard to the treatment of syphilitic 
stenosis due to fibrous-tissue formation after ulceration. This 
should not occur if, upon early recognition of the lesion, proper, 
prompt, and energetic antisyphilitic treatment has been instituted ; 
and it is only in neglected or exceptional cases that such lesions 
exist. Once fibrous-tissue formation with contraction has taken 
place, no amount of internal medication will be of benefit. The 
resulting cicatricial tissue presents the well-known stellate scar, 
with the peculiar contraction and alteration of the contour of the 
part. The division of the stellate bands may relieve somewhat 
the condition ; but the incision that divides the bands brings about 
another inflammation, with its subsequent contraction. Various 
dilators and cutting instruments, as seen on pages 629, 631 (Figs. 
224, 226), can be used. These produce beneficial results, but it 
must be remembered that we are dealing with an inflammatory 
fibrous tissue, and while dilatation may retard and somewhat arrest 
the contraction, it cannot entirely remove the stenosis. The con- 
traction may go on to such an extent as to necessitate the per- 
formance of tracheotomy in order to prolong the patient's life. 

The treatment by the use of salvarsan, as described on page 
156, from the clinical report is certainly justifiable. Although 
sufficient time has not elapsed to definitely determine its curative 
properties, yet the reports are sufficiently favorable to warrant its 
use. 



TUBERCULOSIS OF THE LARYNX. 

Synonyms. — Consumption of the larynx ; Consumption of 
the throat ; Laryngeal phthisis ; Tubercular laryngitis. 

Definition. — A specific inflammatory disease of the larynx due 
to the Bacillus tuberculosis. The affection occurs coexistently with 
a similar process in the lungs, and usually follows it, though rarely 
it may precede. It is characterized by swelling of the laryngeal 
mucosa and development of miliary tubercles, which subsequently 
break down and form minute, spreading ulcers, that coalesce and 
lead to extensive ulceration, with alteration of the laryngeal struct- 
ure. Accompanying the disease is a widely variant train of symp- 
toms, such as voice-impairment, dysphagia, and the like, due not 
only to the local lesion, but also to the pulmonary involvement. 



704 DISEASES OF THE LARYNX. 

The affection runs a more or less rapid course, and is usually of 
grave prognosis. 

Ktiology. — The essential factor is the lodgement and pro- 
liferation of the Bacillus tuberculosis, or Bacillus of Koch, in the 
laryngeal structure. Whether this may be a primary condition 
arising from infection drawn from without the body, or whether it 
is always a secondary manifestation from a pre-existing pulmonary 
consumption, has long been a theme for discussion. With Cohen 
and others the author believes, however, that primary infection 
of the larynx may occur. This view is fully sustained both by 
theoretical considerations and by post-mortem examinations. Such 
cases are sooner or later invariably followed by the establishment 
of tuberculosis in the pulmonary organs. In the vast majority of 
instances, however, it follows rather than precedes the process in 
the lungs. As strong predisposing elements must be regarded the 
tubercular diathesis, a lowered bodily resistance from whatever 
cause, or existent local impairment due to prolonged catarrhal 
inflammations or the like. Any lesion productive of epithelial 
desquamation and permitting free access to the deeper layers of the 
mucosa must be regarded as favorable to its establishment. The 
greater number of cases occur between the ages of twenty and 
thirty-five ; and males, probably from their more exposed life, are 
more frequently affected than females. 

Pathology. — The essential features of the morbid process do 
not present in this location any variance in minute anatomy from 
those exhibited elsewhere. Presented microscopically is the same 
picture of invasion, cell-proliferation, formation of miliary tuber- 
cles, blocking off of nutrition and subsequent softening of the 
tubercles, with discharge of the softened masses and the formation 
of small, spreading ulcers. The perichondrium, if the patient sur- 
vive so long, may be invaded by the tubercular process, and necro- 
sis or caries of the cartilaginous elements takes place. Rarely, 
however, in this organ does nature exhibit a tendency toward 
spontaneous cure, though stenotic conditions do sometimes arise 
through partial attempts at cicatrization. 

Symptoms. — The symptoms of the affliction vary greatly 
according to the case, because of the somewhat wide range of sites 
for the location of the morbid process and its spread, and the 
rapidity of its progress. The disease may extend up the larynx 
from a point near or within the trachea, or its first manifestations may 
be upon the vocal cords themselves. Usually, the posterior region 
of the larynx is the seat of invasion — a fact readily accounted for 
by the bathing it receives in expectoration of infected debris from 
the lungs, and the favoring reception and lodgement of infected 
material which it offers in the prone position. The onset is gen- 
erally insidious, and the course of varied duration. In some cases 
the course is so rapid as to merit a terminology similar to the 



TUBERCULOSIS OF THE LARYNX. 705 

pulmonary phthisis florida. In other cases the course is more 
chronic, and between the two extremes lies a wide range of differ- 
ence in duration of the process. Generally, the patient seeks 
relief for a dry and burning sensation in the throat, attended with 
a progressive hoarseness and weakening of the voice. This annoy- 
ance may have been present for some time, since the existence of 
an acute, subacute, or chronic laryngitis not infrequently precedes 
the establishment of the tubercular lesion. The sensation as of 
foreign bodies in the throat, which irritate and scratch, is very 
commonly complained of. Actual pain in the earlier stages is 
rare, though it may occur. As the process goes on to ulceration, 
however, pain as a subjective symptom may become very urgent, 
both from pressure upon, or oftener, from erosive exposure of, 
terminal nerve-filaments, and its referred location depends upon 
the nervous distribution attacked. Tenderness and pain on press- 
ure or even touch of the throat may, however, be very severe. 
The character of the voice changes, and assumes a nature depend- 
ent upon the causative lesion. Thus the proper approximation of 
the vocal cords may be interfered with through hindrance in the 
working of their mechanism, and the voice show the effect of 
lessened vibration and escape of air not productive of sound. 
Otherwise, ulceration of the cords themselves may take place and 
be responsible for hoarseness and unevenness of tone. Usually, 
the voice becomes hoarse and lower in pitch, and may go on even 
to complete aphonia. The exercise of talking may become so 
painful and difficult as to keep the patient from making the effort. 
Cough is commonly present, and may be attended with little or 
no annoyance ; or, in the later stages especially, be the source of 
the most excruciating agony during paroxysmal seizures. Deglu- 
tition becomes gradually more painful in the majority of cases, and 
is attended by attacks of choking and strangling, which render the 
taking of food difficult and play no small part in causing the gen- 
eral emaciation that is frequently observed. In the late stages the 
regurgitation of food and the drawing of bits of food or of fluid 
into the larynx during inspiration are not uncommon. Secretion 
from the larynx itself is slight but tenacious, and if an excessive 
amount be present, it must be traced to the lungs. Portions of 
eroded cartilage may, however, be expelled in the later stages. 
Dyspnea is a feature that may be present early or late, and may 
require tracheotomy for its relief; and in a small proportion of 
cases a stenotic condition from partial cicatrization of the ulcera- 
tive process may render the same procedure imperative. In addi- 
tion to these symptoms of local reference, the systemic effects of 
the pulmonary lesions are to be noted. This is not the place to 
describe the physical signs of the chest, and mention only need be 
made of the night-sweats, suppurative fever, hectic flush, and general 
pallor and emaciation that are pathognomonic. Hemoptysis is of 

45 



706 DISEASES OF THE LARYNX. 

pulmonary origin, and is rarely ever even slightly increased by 
any blood from the larynx. So, also, the expectoration of muco- 
purulent material is from the lungs and not from the larynx. 

Inspection by the laryngoscope reveals a picture as varied in 
individual cases as are the attendant symptoms. This is due both 
to the variation in location possible in the process and to the some- 
what different appearance in the phenomena of the acute and 
chronic forms. Thus, in the rapid variety there is more of a 
hyperemic appearance of the affected membrane ; while in the 
more chronic form there is a marked anemic condition of the 
membrane which is almost pathognomonic. The diseased areas, as 
already stated, may be observed as an extension of a process located 
lower down in the respiratory tract and gradually working upward ; 
or the morbid manifestations may appear first on the epiglottis, and 
from thence extend downward. They may be on the vocal cords, 
unilateral or bilateral, and not infrequently an apparent coex- 
istence of unilateral laryngeal tuberculosis has been noted, with 
pulmonary involvement of the same side. Usually, however, the 
posterior region of the organ is that in which the process is to be 
seen most clearly and is most plainly in evidence, for the reasons 
already advanced. Excluding the symptoms of an existent catarrhal 
inflammation, there is seen in the infected region at first but little 
to indicate trouble. Later examination shows localized swellings 
of the membrane, which only in the acute form reveal noticeable 
hyperemia, and in the chronic form are decidedly anemic. These 
areas of swelling increase in size and spread. Sometimes they 
become so large as to cause dyspnea, especially if they occur in 
the tissues near the laryngeal inlet. The epiglottis is a favorite 
site for tubercular infiltration, and this organ may assume a simple 
globular, puffed form, a thickened crescentic shape, or simulate the 
Turkish turban — the so-called " turban " epiglottis. Swelling of 
the arytenoid regions is common, and a peculiar rounded tumes- 
cence of the arytenoid prominences has originated the desig- 
nation of the " club-shaped " arytenoids. Within the mem- 
brane, which becomes progressively paler and anemic, are soon 
to be observed the presence of countless numbers of bodies 
like small, yellowish seeds, plainly visible beneath the investing 
covering. These increase in number and degenerative changes 
occur; they soften and discharge their contents, and numerous 
small ulcers mark their sites. With the formation of these small, 
necrotic areas the beginning of the final stage of the process is 
ushered in. They spread, coalesce, and form larger areas, and 
these in turn unite in the necrotic extension. The total facies of 
the larynx changes, and may present a picture, at different stages, 
of discrete, small, but spreading ulcers, with well-defined margins 
without marked adjacent phenomena, shallow, with a dirty, ragged, 
grayish floor, and covered with a grayish, ropy secretion ; or the- 



TUBERCULOSIS OF THE LARYNX. 707 

image may be that of a larger involvement of the larynx in a 
rough, ulcerated, irregular, and altered contour of its lining sur- 
face. In the later stages it may, in exceptional cases, be even pos- 
sible to observe exposed cartilage, and in more frequent instances 
the stump of an ulcerated epiglottis. The vocal bands, as a rule, 
are not markedly affected until the process has been present some 
time ; but gradually they lose their luster, become dingy, and 
ulceration occurring, all sorts of dentations and roughenings may 
be found on their margins. On the other hand, involvement of 
the cords may be among the earliest of the manifestations, and 
between the two extremes is a large range of varying degrees. 
Occasionally, on the edges of the cords may be seen small vegeta- 
tive projections ; and rarely, between two ulcerated areas, an adhe- 
sive union may take place. Throughout the whole process it may 
at times be possible to observe attempts of nature toward a repar- 
ative process. Finally, the author wishes again to emphasize the 
fact that few conditions present so varied, and yet, on the whole, 
pathognomonic manifestations, which baffle all attempts at a 
thorough description, as does tuberculosis of the larynx. In 
addition to this diverse exhibition of tubercular signs and symp- 
toms, must be borne in mind the possible coexistence of a mixed 
infection. 

Diagnosis. — This is not usually of much difficulty, especially 
if, as is commonly the case, demonstrable pulmonary lesions are 
present. Time is an important factor in doubtful cases of laryn- 
geal location, especially in the various forms of laryngitis occurring 
coincidently with pulmonary phthisis. The presence of tubercle 
in the sputa is evidence only of tubercular lesion in the respiratory 
tract, and must not be held of localizing importance unless marked 
laryngeal symptoms accompany ; besides, in laryngeal tuberculosis 
the sputum rarely ever shows the bacilli as they are located in the 
tissue. Syphilis may be differentiated by its history, by the char- 
acter of the yellowish discharge on its ulcers, their irregular contour 
and edges, lack of previous tubercle-formation, and the reddened 
areola which surrounds them. Constitutional symptoms should 
be taken into account and the therapeutic test applied. The latter 
will also be employed in determining the existence of a dual infec- 
tion. The nodular swellings of lupus may confuse ; but these have 
no secretion and do not present the same ulcerative and painful 
character, cough, expectoration, or constitutional symptoms. Ma- 
lignant disease is attended by more livid hyperemia in the early 
stages, and greater necrosis and more profuse secretion in the later 
periods of well-established ulceration, while the pain is of a sharp, 
lancinating character. 

The following table by Joseph S. Gibb shows the main points 
of differential diagnosis : 



708 



DISEASES OF THE LARYNX. 



Syphilis. 



Pain usually slight. 

Attacks any portion 
of larynx and ul- 
cerates rapidly. 



Is rarely seen in the 
stage of induration, 
the first evidence 
being a clear-cut, 
deep ulcer. 

Some induration 
around the ulcer, 
but usually very 
little edema. 

Ulcerextends deeply, 
often involving car- 
tilage. 

Surface of ulcer cov- 
ered by mucopuru- 
lent secretion and 
necrosed tissue. 

Mucous membrane 
hyperemic and in- 
jected. 

Laryngeal stenosis 
not common until 
cicatrization oc- 
curs. 

General health un- 
impaired. 



Frequently evidences 
of syphilitic disease 
in other tissues. 

Rapidly improves 
under the iodids. 



Carcinoma. 



Pain constant, lanci- 
nating. 

Attacks any portion 
of larynx, and ul- 
cerates more slow- 
ly than syphilis. 



The first appearance 
is that of a new 
growth occupying 
the laryngeal cav- 
ity; no clear-cut 
ulcer. 

The growth fills or 
encroaches on the 
laryngeal cavity. 

Growth extends in 
all directions, in- 
volving all tissues 
in its course. 

Surface of growth 
covered by dis- 
charge. 



Mucous membrane 
hyperemic. 

Laryngeal stenosis 
quite common. 



Early in disease no 
impairment of gen- 
eral health : later a 
marked cachexia. 

In primary laryngeal 
carcinoma no other 
involvement until 
later in the disease. 

Iodids have no influ- 
ence on the course 
of the disease. 



Tuberculosis. 



Pain severe on deg- 
lutition. 

The favorite site is 
in the interaryte- 
noid space or the 
base of arytenoid 
cartilages ; ulcer- 
ates slowly. 

Usually the first ap- 
pearance is small 
spots of indura- 
tion, which is rap- 
idly followed by 
great edema. 

Great edema of ary- 
tenoids. 



Ulcer extends later- 
ally, but not deep- 
ly- 

Surface of ulcer cov- 
ered by thick mu- 
copurulent secre- 
tion and aggluti- 
nated mucus. 

Mucous membrane 
pale. 

Laryngeal stenosis 
rarely occurs. 



Health impaired 
previous to laryn- 
geal involvement. 

Previous and coinci- 
dent pulmonary 
trouble common. 

Iodids have no in- 
fluence. 



Lupus. 



No pain. 

Attacks any portion; 
ulcerates very slow- 
ly- 



Nodular masses. 



Little or no edema. 



Very slow in prog- 
ress ; ulcer rarely 
observed. 

Little or no discharge. 



Mucous membrane 
injected. 

Slight stenosis. 



Very slight impair- 
ment of general 
health. 

Frequently cutaneous 
manifestations. 



Iodids have no influ- 
ence. 



Prognosis. — As a rule, most unfavorable. A few cases are 
on record of undoubted laryngeal tuberculosis in which very early 
recognition of the character of the disease was made, and removal 
or destruction of the affected areas has been followed by no further 
manifestations. As a rule, the prognosis can be given only on the 
basis of the weeks or months of life yet before the patient. 

Treatment. — The early recognition of the disease by clinical 
examination and bacteriological observation is of great importance, 
as much better results can be obtained by climatic treatment in 
this early stage of the disease than later, when the tissues are 
more extensively involved and the breaking-down process has 
taken place. "While many believe that just as good results can be 
obtained in the low altitudes by the open-air treatment, my own 
experience has been that the high, dry climate is much better, 
and I certainly urge the individual to place himself in such 
climatic conditions "at as early a date as possible. Tuberculosis 



TUBERCULOSIS OF THE LARYNX. 



709 



of the larynx usually occurs secondarily to pulmonary tubercu- 
losis, although primary involvement may occur. The treatment 
in either case is the same, although the prognosis in the pri- 
mary condition is more favorable than when the disease is de- 
pendent upon pulmonary lesion. Much can be done by local 
treatment to retard the progress of the disease, and possibly in 
some cases a cure may be effected. As a rule, the condition 
when presented for treatment has advanced to ulceration. Re- 
peated and thorough cleansing of the part should be instituted 
at once. This can best be accomplished by spraying the parts 
with hydrogen peroxid (15 volume), followed by an alkaline anti- 
septic solution, such as biborate and bicarbonate of sodium, of each 
10 grains to the ounce of aqueous extract of hamamelis and dis- 
tilled water, in equal parts. For this purpose the syringe shown 
in Fig. 233 is useful. After cleansing and drying, the ulcerated 




Fig. 233.— Dennis's antiseptic syringe with laryngeal and antral attachment. 

surface should be carefully touched with dilute nitric or hydro- 
chloric acid. The frequency of such applications must be left to 
the judgment of the physician, based on his knowledge of the 




Fig. 234.— MacCoy's flexible acid-applicator. 



case ; but, as a rule, once daily is sufficient. Lactic acid is highly 
recommended, but I do not find it any better than the dilute 
hydrochloric acid. For intralaryngeal applications of acid solu- 
tions the instrument shown in Fi<r. 234 answers admirablv. I 



710 DISEASES OF THE LARYNX. 

have used the extract of suprarenal capsule in a few cases with 
beneficial results. If the ulcer is deep, curetment under cocain- 
or eucain-anesthesia should be done. The curetment should be 
thorough, as it must be remembered that the tubercular area is 
surrounded by a limiting membrane, and unless the infected tissue 
be thoroughly removed, the breaking up of the protecting mem- 
brane may be the means of rapid dissemination of the tuberculous 
infection through the lymphatics or blood-channels. After thor- 
ough curetment the patient should be sent to a suitable climate. 
Solly of Colorado Springs, who has a large experience in the dis- 
ease, highly advocates this plan. It is unquestionably the plan in 
primary tuberculosis of the larynx, which is a rare condition. It 
is also in these primary cases that the performance of laryngec- 
tomy produces cure. Ernest Crapon recommends laryngofissure 
as beneficial in some cases. In cases in which the ulceration is 
not far advanced or the process is somewhat limited, after the 
cleansing and drying of the surface there should be applied 
directly to the ulcerated area, either by means of spray or 
applicator : 

~fy. Creasoti, 3J (4.0) ; 

Olei picis liquids, gtt. xx (1.3) ; 

Alboleni (liquid), flass (15.0).— M. 

Castor oil may be substituted for the albolene on account of its 
viscid and tenacious properties, but I find it productive of no 
better results. 

The most distressing symptom experienced by the patient is 
the constant pain, which is especially aggravated by swallowing. 
A number of agents are recommended for the relief of this con- 
dition, no single remedy being efficacious in all cases. The sim- 
plest and the one from which I have obtained the best results is 
the juice of the ordinary pineapple, applied by means of spray or 
applicator, although in some cases I find it is irritating. This 
can be frequently repeated without any ill effects. Cocain, in a 6 
to 10 per cent, solution as a spray, will give relief, but it is not 
lasting and requires frequent repetition. Inhalation of benzoin or 
insufflation of orthoform gives partial relief. For the irritating 
cough : 

1^. Extracti hydrastis canadensis fluidi, 

Extracti ergotse fluidi, ad fl^j (30.0). — M, 

15 to 40 drops of the solution after meals and at bedtime, given 
in plenty of water, may be used. For relief of the burning sensa- 
tion in the throat and the cough due to local irritation, the follow- 
ing gargles or sprays should be used : 



TUBERCULOSIS OF THE LARYNX. Ill 

~fy. Extracti hydrastis (colorless), 
Hydrogenii peroxidi, 
Aquse cinnamomi, equal parts. 

with 2 per cent, cocain solution added. Should there be dryness 
of the parts, a solution of : 

^. Menthol, gr. iv (0.25); 

Olei santali, gtt. iv (0.25) ; 

Alboleni (vel benzoinol), fl^j (30.0).— M. 

will lubricate the surface and relieve the irritation. Cracked ice 
acts favorably and gives some temporary relief. Liquid diet 
should be instituted and no irritating condiments used. In the 
advanced stage of the disease, in which the treatment is purely 
palliative, narcotics may have to be administered to relieve the 
intense suffering. 

The application of electricity has been recommended, and is 
worthy of trial. The application of remedial agents, using elec- 




Fig. 236. 



Fig. 235.— Scheppegrell's laryngeal electrode and handle for cupric electrolysis, with extra 
spherical points (Fig. 236). 




=^0 

Fig. 237.— Electrode for direct laryngoscopy. 

tricity for the passage into the tissue — cataphoresis — is good. 
Cupric interstitial electrolysis, which forms in the tissue oxy- 
chlorid of copper, is highly beneficial, as reported by Scheppe- 
grell (Figs. 235, 236). 

Intralaryngeal injections of creosote and guaiacol are produc- 
tive of good results, at least alleviating, if not curing, all cases. 

James Donelan of London has reported success in the treat- 
ment of several cases of tubercular laryngitis by injections of 
guaiacol, for which purpose he has devised a special form of syringe 
(Fig. 238). It consists of a steel barrel mounted on a modified 
handle. Instead of a piston-rod and leather piston there is 
a steel plunger, graduated in minims and fitting accurately to 
ensure the propulsion of fluids. It is easily sterilizable. The 



712 



DISEASES OF THE LARYNX. 



fcechnic of the operation is as follows : The larynx is first cleansed 
with an antiseptic spray ; then the needle of the syringe is inserted 
at the desired site, and 1 minim of pure guaiacol is injected into 
the floor of the ulcer or most prominent part of the infiltration. 
The local reaction is slight, and is easily controlled by rest and 
by sucking ice. The injections are continued at intervals of a 
week. There is no danger or inconvenience from the treatment, 
which is attended with gratifying results, particularly as regards 
the relief of dysphagia. 

The deep injections of alcohol, beginning with a weak solution 
and gradually increasing the strength to absolute, act favorably 
in some cases. One-tenth of 1 per cent, formaldehyd, with 2 per 




Fig. 238.— Donelan's injection-syringe for intralaryngeal tuberculosis. 

cent, cocain locally applied, has a decided effect in lessening the 
tendency to spread. 

The constitutional treatment should consist in the administra- 
tion of such drugs as will improve the general nutrition — cod-liver 
oil, iron, hypophosphites, or the arsenical preparations — and if the 
tubercular tendency be recognized early, the patient should be 
placed under suitable climatic conditions. 

The local injection of alcohol for the relief of intractable neu- 
ralgia of the various branches of the fifth nerve, originated by 
Schlosser, is now a well-established means of treatment. For the 
application of this method to the dysphagia of laryngeal tubercu- 
losis we are indebted to Rudolph Hoffmann, of Munich. Dundas 
Grant highly recommends this treatment, which, in these cases, 
consists in the injection of the internal branch of the superior laryn- 
geal nerve. The duration of the relief is the striking feature. The 



LARYNGEAL HEMORRHAGE. 713 

solution consists of 2 grains of hydrochlorid of ,3-eucain in an ounce 
of 80 per cent, alcohol. The method of injection is as follows : The 
patient is placed in a horizontal position, and with the thumb of 
the left hand the sound side of the larynx is pressed toward the 
middle line so that the affected half projects distinctly ; the other 
fingers of the hand lie on this. The index-finger enters the space 
between the thyroid cartilage and the hyoid bone from without until 
the patient announces that a painful spot has been reached. The 
nail of the index-finger is now placed upon the skin in such a way 
that the point of entrance for the needle lies opposite its middle. 
The needle is pushed in for about 1 .5 cm. This distance is marked 
off on the needle perpendicular to the surface of the body. Accord- 
ing to the thinness of the subcutaneous layer of fat, the perforation 
has to be more or less deep. The needle is then carefully moved 
so as to seek a spot at which the patient feels pain in the ear. The 
syringe, filled with the alcohol, warmed to a temperature of 45° C. 
(113° F.), is screwed to the needle and the piston slowly pressed 
down. The patient now feels pain in the ear, the passing off of 
which he indicates by raising his hand. During the operation 
swallowing and speaking must be avoided. The injection is kept 
up until no further pain occurs in the ear ; then the needle is re- 
moved and collodion is applied. The point of the needle is bev- 
eled much more obtusely than the ordinary hypodermic needle to 
avoid the danger of puncturing a vessel. 



LARYNGEAL HEMORRHAGE. 

Laryngeal hemorrhage includes rupture of a blood-vessel of the 
larynx, with escape of blood into the submucous tissue, causing 
hematoma, and also the surface escape of blood from the mucous 
membrane. When interstitial and slight it causes inflammation, 
and has been described under Hemorrhagic Laryngitis (page 666). 

Etiology. — The causation of hemorrhage from the laryngeal 
structure, in all probability, is due in the majority of cases to sys- 
temic lesion. Hemophilia, cirrhosis of the liver, diseases such as 
dilatation of the heart, advanced phthisis, benign or malignant 
growths, anemia, malnutrition, vicarious menstruation, or preg- 
nancy, may bear causal relation to the condition. In some instances 
it may occur while the patient is apparently in good health. Slight 
erosion, due to trauma or coughing, vomiting, straining, violent 
exercise, or other conditions which cause superficial congestion, 
may also lead to laryngeal hemorrhage. 

Symptoms. — If the escape of blood be confined to the sub- 
mucous tissues, the symptoms may consist of irritation in the 
larynx, with tendency to cough, change in the voice, and difficulty 
in breathing, if the tumor be large enough to encroach on the 



714 DISEASES OF THE LARYNX. 

lumen of the larynx. The escape of blood with slight effort by 
the patient, appearing in small streaks or masses unmixed with 
saliva or mucus, or, when small in amount, lodging in the larynx 
and becoming clotted, and being subsequently expelled as small, 
dark-colored masses, continuing for some days without great vari- 
ation in amount, constitutes the symptomatology of this condition. 

Diagnosis. — Differentiation between hemorrhage of the lungs 
and this condition is made partly by laryngoscopic examination, 
by examination of the lungs, and by the fact that in pulmonary 
hemorrhages the- blood is usually thoroughly mixed with mucus, 
the latter not being the case in bleeding from the larynx. As 
hemorrhage from the nasopharynx or nose may trickle down into 
the larynx, examination of the postnasal spaces should also be 
made in substantiating the diagnosis. 

Prognosis. — The danger to life is not marked, as fatal cases 
of laryngeal hemorrhage are exceedingly rare. 

Treatment. — If the hemorrhage is concealed, as in the form 
of a hematoma, and encroaches upon the lumen of the larynx, giving 
rise to symptoms of interference with respiration, the tumor should 
be incised and the clot turned out. In open hemorrhage the flow 
of blood is generally controlled by spraying with 3 to 10 per 
cent, alumnol solution, together with the internal administration 
of ergo tin in 1 -grain doses every two hours for three or four doses, 
then three times daily ; or the administration of chlorid of calcium 
in 5-grain doses, diluted with a half-glass of water or milk, three 
or four times a day, may be beneficial, though not always reliable. 
The voice should be kept at rest, exercise avoided, bland and 
unirritating food ordered, condiments and highly seasoned food or 
drink forbidden, small pieces of ice held in the mouth, or cold 
applied in this form externally to the neck. If the cough be 
troublesome and annoying, codein should be administered in -J- 
grain doses every hour, until effect is produced. Any systemic 
lesion should be carefully sought for and corrected. 

BRONCHOSCOPY. 

Under this heading the principles involved and the technic 
used can be applied also to Laryngoscopy, Laryngobronchoscopy, 
Tracheoscopy, Esophagoscopy, Gastroscopy, and, possibly, Mag- 
netism. 

For a number of years various operators have attempted direct 
inspection of the larynx, trachea, and bronchial tubes, and vari- 
ous methods have been devised, some fairly successful, for the 
inspection of these structures. By the use of mirrors a fairly 
good view can be obtained, but by direct inspection the process is 
much simplified. 



BRONCHOSCOPY. 715 

Frequently, in fact in the majority of cases, the obstruction 
within the upper respiratory tract is below the point where direct 
inspection is of value from a diagnostic or treatment standpoint. 
This is especially true of foreign bodies. Foreign substances may 
be introduced with food and drink, and the individual may not be 
conscious, at the time, of the presence of the foreign body until it 
lodges within the structures ; or the accidental inhalation of a 
foreign body may only be realized by the sudden onset of a series 
of symptoms which calls the individual's attention to the presence 
of the foreign body. It is frequently observed in adults that the 
individual is not certain whether or not he drew the foreign body 
into his throat ; he has a sensation of its presence, but does not 
recall having swallowed or inhaled it. Again, even if he is posi- 
tive of the presence of the foreign body, he is unable to determine 
its location. In children the location of the foreign body by sen- 
sation is even more difficult. 

Sharp-pointed bodies or any foreign substance that will lacerate 
the tissue involve a question of judgment as to the best method of 
removal. An open safety-pin, for example, will be difficult of 
extraction by any instrument, and it might involve less risk to the 
patient to make the open incision, than to lacerate and tear the 
tissues by a forcible removal of such an object. Also, if the 
foreign body can be located in a short time after its presence has 
been detected and before any inflammatory symptoms have begun, 
the process will be much simplified. If, however, the inflamma- 
tory process has begun, the location and extraction of the foreign 
body becomes more difficult. 

The foreign body may also become encysted. On account 
of inflammatory action, with infection, the tissue may slough, 
loosening the foreign body, and the patient, in a spasmodic fit of 
coughing, may expel it. 

Metallic foreign bodies can be removed by magnet, after the 
method suggested by de Roaides. 

During anesthesia a foreign body may be unconsciously drawn 
into the respiratory tract and a persistent cough follow. Such a 
case came under my notice several years ago. The patient, a 
young woman twenty-two years of age, under nitrous oxid had a 
tooth extracted. Almost immediately after the patient returned 
to consciousness she complained of an irritation in her right 
lung and developed a rasping, hacking cough. This cough per- 
sisted and a localized spot could be distinctly outlined in the 
right lung. The patient had a slight temperature, began to lose 
flesh, and although no tubercle bacilli were found in the sputum, 
yet from the general symptoms developed her physician sent her 
to a high, dry climate. She did not improve and in despera- 
tion returned home. A few days after her return, in a fit of 



716 



DISEASES OF THE LARYNX. 



coughing, she expectorated a small prong of tooth, which had 
evidently been drawn into the lung at the time of extraction. 
After the expectoration of this foreign body the lung gradually 
cleared up and the patient made an uninterrupted recovery. 

I certainly agree with Jackson that many curious cases of per- 
sistent cough and obscure bronchial or so-called lung trouble 
could be traced to some foreign body. The bronchial irritation or 
the persistent hacking cough may be due to the lodgment of some 
foreign body in the upper respiratory tract or in the esophagus. 

For direct inspection of the larynx, in the recumbent position 
with the head drawn over the table, the Kirstein otoscope will give 
the observer an excellent view of the larynx. 

Under anesthesia, by the aid of the laryngoscope, a fairly good 
examination can be made. By the aid of the Rontgen ray in 
many cases the foreign body can be located, but, unfortunately, 




Fig. 239.— Chevalier Jackson's bronchoscope with slanting end to facilitate introduction. 



certain foreign bodies are not outlined by the Rontgen ray and can 
only be located by direct inspection. It can also be used to de- 
termine the direction of instruments. Jackson believes that the 
Rontgen ray, if properly used and the plates properly developed, 
will locate almost any foreign body. 

By placing the patient in a recumbent position and bringing 
the shoulders to the edge of the table, allowing the head to drop 
over the edge, the operator sitting directly behind the patient, 
under complete anesthesia or even under local anesthesia, by 
elevating the epiglottis by means of the spatula, a fairly good 
direct inspection of the larynx can be made without the aid of any 
tube. 

The bronchoscope, then, is a valuable addition to the armamen- 
tarium necessary for the treatment of diseases of the upper respir- 
atory tract, and the profession owes much to Professor Killian, of 
Freiburg, and Chevalier Jackson^ of Pittsburg, for their labors in 



BRONCHOSCOPY. 



717 



this line and for the perfection of such excellent instruments. 
The methods advanced by them and the instruments devised and 
recommended by them are certainly the most satisfactory. 

To be sure, the technic requires a skilful and practised 
hand, but can be acquired by any one with persistent practice. 
The instruments certainly should first be used on the manikin or 
cadaver, so as to familiarize the observer with not only the 
handling of the instrument, but also to familiarize himself with 
the appearance of these structures, both normal and abnormal. 

Instruments. — The instruments for removal will depend 
entirely on the nature, position, shape, and size of the foreign 




Fig. 240. 



-Double bronchoscopic battery, one cord being for the separable speculum and 
the other for the bronchoscope. 



body, whether it is imbedded or not imbedded, whether it is a 
recent accident or a chronic case. The instruments necessary, as 
suggested and recommended by Chevalier Jackson, are shown in 
Fig. 242. 

One advantage of bronchoscopy is that, no matter to what par- 
ticular structure it is applied, if the operator fails to locate the 
foreign body, he certainly can do no harm to the patient. 

The sterilization of instruments and the general clinical pro- 
cedure does not differ from other operations. 

Various methods have been suggested, but the principles in- 
volved in the methods given by Killian and Jackson are the essen- 
tial ones. Chevalier Jackson's l method is as follows : 



1 1 am indebted to Chevalier Jackson for kindly furnishing me with this copy 
of his exact technic. 



718 



DISEASES OF THE LARYNX. 



TECHNIC OF LARYNGO=BRONCHOSCOPY, ESOPHAGOSCOPY, 
AND DIRECT LARYNGOSCOPY. 

" Superior Bronchoscopy. — The patient is placed in a 
dorsal position upon an operating table having a dropping head- 
board and chloroform is given. When deeply anesthetized, the 
head is held in the air by an assistant, the head-board being 




Fig. 241.— Separable speculum for passing bronchoscopes. The detachable handle 
(A B) is needed for locally anesthetized patients in the sitting position or when the spec- 
ulum is held by an assistant. 

dropped. The extension of the head should be entirely at the 
occipito-atlantal joint and not at the intervertebral cervical artic- 
ulations. The illuminated slide speculum is introduced with the 
left hand, the extremity of the speculum being passed in the 
median line along the center of the dorsum of the tongue until 
the epiglottis conies into view. The tip of the instrument is 
passed posteriorly to the epiglottis for the distance of about 1 cm. 
beyond the tip. The end of the instrument is then given a strong 
lifting motion, by which the epiglottis is lifted strongly and with 
it the base of the tongue and the tissues in the region of the 
hyoid bone. This brings the upper orifice of the larynx into 
view (A, Fig. 248). The bronchoscope, which is illuminated 
by a separate cord from the same battery as the speculum, is 
passed through the speculum well into the trachea, as shown at B. 
The speculum is then removed, as shown at C and D, leaving the 
bronchoscope in the trachea. Once in the trachea, the explora- 
tion of the bronchi is easy. It is usually wise to cocainize the 
bronchial mucosa to overcome the cough reflex, which otherwise 
will be troublesome unless the anesthesia be dangerously deep. A 
small dose of codein or morphin hypodermically preliminary to 



BRONCHOSCOPY. 



719 




Fig. 242.— Instruments for tracheobronchoscopy and esophagoscopy : A, Chevalier Jack- 
son's 10 mm. X 53 cm. esophagoscope for adults ; B,*7mm. X 40 cm. bronchoscope for adults ; 
C, aspirator for esophagoscopes, occasionally used on bronchoscopes also; D, 7 mm, X 45 
cm. esophagoscope for infants and children ; E, 5 mm. X 30 cm. bronchoscope for 
infants and children ; F, Mosher's forceps for the larynx and upper end of the esophagus ; 
G, 7 mm. X 20 cm. tracheoscope for adults ; H, Ferguson's mouth-gag; I, 5 mm. X 14 cm. 
tracheoscope for infants and children; J, Sajous' laryngeal forceps for cocainizing the 
larynx ; K, Jackson's endoscopic forceps ; L, Coolidge's cotton holders ; M, Jackson's slide 
speculum for direct laryngoscopy and for introducing bronchoscopes. 



720 



DISEASES OF THE LARYNX. 



operation obviates this, and atropin may be added to lessen 
secretion. Care should be taken not to insert the speculum too 
far and thus enter the mouth of the esophagus, an error very 




Fig. 243.— Separable speculum in position for direct examination of the larynx, or for 
the passage of bronchoscopes. Patient sitting. Local anesthesia. The extra handle 
affords the necessary leverage. 

likely to occur if the inferior constrictor of the pharynx is mis- 
taken for the epiglottis. 

" A very important part of endoscopy is the management of 
the electric light, which in some form is absolutely essential. A 
little knowledge of how to hunt for causes of ' no light ' can best 
be learned from an electrician. 

" When during a prolonged examination the light becomes 
reddened with blood or dimmed, it is not necessary to remove the 
bronchoscope. The light carrier is withdrawn and the lamp 
cleansed with a damp sterile gauze sponge, or the light readjusted, 
if need be, to full illumination. Secretions should be wiped away 
by passing an applicator (L, Fig. 242), armed with cotton or 
with a minute folded gauze sponge, down the tube. Occasion- 
ally a case will be encountered in which the secretions are so 
abundant that sponging will not remove the secretions rapidly 
enough. In such cases the small tube connected with an aspirator 
may be passed down the bronchoscope or, better still, the broncho- 
scope with an auxiliary drainage canal made in its wall, as in the 
esophagoscope, may be used. This will maintain a dry field in 
spite of any amount of secretion. There are side openings in the 
bronchoscope, so that, should it enter a bronchus completely 
occluded by a foreign body, respiration may still go on safely 
through the side opening. 

" In foreign-body cases, hooks, probes, and forceps will be neces- 
sary. In the use of full-curved hooks care must be exercised lest 
the hook catch in a branch bronchus. Only hooks of partial 



BRONCHOSCOPY. 



721 



curve or straight probes should be used for passage out of sight 
into a small branch bronchus. A swollen bronchial orifice with 
reddened mucosa or the escape of secretion will indicate which 
bronchus contains the intruder. 

" KsophagOSCOpy differs from superior bronchoscopy only in 
that the distal end of the esophagoscope, with its obturator within 




Fig. 244.— Position of the hands in passing the esophagoscope. 

it, is passed through the speculum into the right pyriform sinus 
for a few centimeters, when the slide speculum is removed and 




Fig. 245.— Position of assistants, nurses, operators, and patients during the introduc- 
tion of the esophagoscope. Second assistant should sit on a stool instead of kneeling on 
the floor, 



also the obturator, after which the esophagoscope is passed by sight. 
The battery cord and the tubing of the aspirator are attached 
as soon as the speculum is removed. The esophagoscope may be 

46 



722 DISEASES OF THE LARYNX. 

introduced in other ways. One way is by using the finger for a 
guide, as in intubation, the difference being that the esophago- 
scope is started into the angle of the mouth, with the axis of the 
tube coinciding as nearly as possible with the axis of the esoph- 
agus and the tube end is guided to the right side of the right 
arytenoid into the right pyriform sinus. Another way is to pass 
a flexible esophageal sound first and then pass the esophago- 
scope without its mandrin outside of the bougie, which thus 
becomes a pilot. Care must be taken that the bougie is not 
pushed downward into the stomach. The best way is the method 
readily understood by reference to Fig. 244. The esophago- 
scope is passed into the right corner of the patient's mouth, 
following the side of the operator's left index-finger, which is 
lifting strongly on the cricoid cartilage. In adults the finger 
cannot reach the cricoid cartilage and the lifting is done on the 
hyoid bone. This lifting opens up the mouth of the esophagus 
and the esophagoscope is guided into the esophagus. It is very 
important to bear in mind the general direction of the esophagus 
by watching the neck and face of the patient. Once the tube- 
mouth enters the mouth of the esophagus, the obturator is 
removed and the esophagoscope is passed by sight, being careful 




Fig. 246.— Diagram showing occlusion of the trachea by faulty direction of the esoph- 
agoscope. 

to follow the esophageal axis, otherwise the accident shown in 
Fig. 246 may occur." 

The use of the esophagoscope is illustrated in the following 
case which came under the author's observation, and which is 
quoted in full : 

Early in the morning of October 15, 1895, the patient was suddenly awakened 
while dreaming — dreaming that he was swallowing egg-shells. On becoming thor- 
oughly conscious he realized that he was actually swallowing some hard object, 
and investigation promptly disclosed the fact that an upper suction plate with four 
attached front teeth, which he had left in place on retiring, was missing. Insert- 
ing his finger into his throat he was able to touch the plate, but in his effort to 
grasp it only succeeded in pushing it further down. A physician was called, made 
an examination, but could see nothing. As the patient could feel that the plate 
was lodged in the upper part of the esophagus, the physician wanted to attempt 
pushing it down into the stomach. To this procedure the patient objected, and 
then went to a hospital, where another physician examined him, passed^ bougies 
and probangs, but with no result whatever, and ended by assuring the patient that 
he had never swallowed the plate, or, if he had, that it was no longer in the 
esophagus. 



BRONCHOSCOPY. 



723 



During the first three weeks following the disappearance of the plate the 
patient experienced slight pain in the lower part of the neck, at the point where 
he always felt the object had lodged. After that time there was practically never 
airy painful sensation, but swallowing had always been difficult. When solid food 
— meat, potatoes, etc. — were taken, they had iirst to be finely ground. For months 
at a time he took only liquids. At the time of the accident his age was fifty-five 
veal's and his weight 138 pounds. After about the second year he began to notice 
he was losing weight, and continued to do so until the time he came under my 
observation, when, at the age of seventy-two, he weighed but 110 pounds. 

In 1901, six years after the disappearance of the teeth, the first x-ray plate 
was made in a further attempt to locate them. The plate appeared to show a 




■■H 



Fig. 247.— Suction tooth-plate distinctly shown resting in the esophagus immediately 
behind the cricoid cartilage and upper tracheal rings. 



slight shadow just above the cardiac end of the esophagus. The passing of bougies, 
however, failed to disclose the presence of a foreign body in that region, and again 
the search was abandoned. 

The patient's general condition continued the same until about the middle of 
January, 1913, when the difficulty in swallowing beyond a certain point was mark- 
edly increased. On January 27, 1913, the patient was referred to me by his family 
physician, Dr. W. H. Hartzell. An x-ray plate was at once made (Fig. 247). The 
negative (lateral view of the neck) showed distinctly the plate, its long axis par- 
allel to the walls of the esophagus, and located immediately behind, and extending 
a little below, the cricoid cartilage. The teeth were attached to the lower end of 
the plate. The same evening the patient was taken to the operating-room, and 
the removal of the teeth attempted. The pharynx and esophagus were anesthet- 



724 DISEASES OF THE LARYNX. 

ized with 20 per cent, solution of cocain, and the patient placed on a table with 
his head well extended over the end. The extension of the head on the shoulders 
was very difficult, owing to rigidity of the entire spinal column. An attempt was 
made to secure a view of the plate by means of the Kirstein autoscope, but this 
was found to be too short, and the Kahler esophagoscope (Fig. 249) was used 
instead. With this instrument a portion of the surface of the plate was brought 
to view, about 18 cm. below the anterior margin of the upper jaw, but the upper 
edge appeared to be covered by fibrous tissue. 

Efforts were made through the esophagoscope, with various forms of forceps, 
to find and grasp the edge, but without result. The esophagoscope was then re- 
moved, and an attempt was made with an ordinary long laryngeal forceps. I was 
able to partially displace the thickened tissue over the upper margin of the teeth, 
so that with the laryngeal forceps a hold was secured, but considerable force failed 
to dislodge the plate. It was then decided to allow the patient to rest for a time. 
"Very little soreness and practically no hemorrhage followed this manipulation. 

On January 30 a second attempt was made, the patient anesthetized as before, 
but this time sitting on a low stool with head and back supported by an assistant. 
This position was found to be much easier for both patient and operator. On this 
occasion, through the Kahler esophagoscope, a portion of the tissue covering the 
upper edge of the plate was cut away with biting forceps, thus exposing it to view. 
Seizing the plate with the same forceps an effort was made to withdraw it, but the 
forceps slipped off and the plate remained. After similar repeated efforts, owing 
to the fatigue of the patient, it became necessary to again cease manipulation for 
a time. 

In the meantime another instrument, a long, biting forceps, suitable for use 
through the Kahler esophagoscope, had been secured, and on February 4 a third 
attempt was made, in all respects similar to the second, except that the new biting 
forceps was used for cutting away more of the overhanging tissue and grasping 
the plate. The plate was distinctly loosened from its bed at this time, but not 
sufficiently to be withdrawn before weakness of the patient and slight hemorrhage, 
which obstructed the view, made it seem advisable to discontinue a third time. 

On February 10 the patient was prepared as before, and, with the Kahler 
esophagoscope. the plate was promptly located and grasped w T ith the biting forceps, 
which held while steady traction was made. The plate moved slightly — perhaps 
half or three-quarters of an inch — when the forceps slipped off. The esophago- 
scope was readjusted, the assistant supporting the head was directed to apply ex- 
ternal pressure to the foreign body in a direction backward and upward, the plate 
was again seized, steady upward traction applied, and esophagoscope, forceps, and 
teeth all steadily withdrawn. 

The plate and teeth were found to be in a perfect state of preservation. 
The plate measured If inches in length by 1J inches in its greatest breadth. 
Practically, no hemorrhage and very little soreness followed the final operation. 
The second day after the removal of the plate difficulty was experienced in swal- 
lowing. This difficulty in swallowing was not due to any swelling, but to the fact 
that there was no muscular action in the esophagus, and the portion involved by 
the foreign body was almost the same as the saccular dilation ; in other words, 
the cause of the lateral distention in the esophagus had not been removed and 
the physiological contraction did not take place. Liquids taken appeared to be 
arrested in the pocket which the plate had formed in the anterior wall of the 
esophagus. It was found, however, that by taking a very small portion of liquid 
at a time it could be swallowed without great difficulty. 

Local anesthesia was used in the foregoing operation, first using 
a 5 per cent, solution of cocain in the upper part of the esophagus, 
and then by means of an atomizer through the esophagoscope a 20 
per cent, solution was used further down. 

The scar-tissue formation was not circular, but was limited to 
the point of impingement of the suction plate at its widest diam- 



BRONCHOSCOPY. 725 

eter, as is shown in the #-ray. This made two areas of scar tissue, 
one on each lateral wall. However, at the top of the plate, on 
account of the friction, granulation tissue had formed and ex- 
tended out over the upper margin of the plate. This tissue was 
almost a quarter of an inch in thickness and extended down over 
the plate a considerable distance. This scar tissue was removed at 
one margin of the plate, so as to enable me to pass an instrument 
underneath the plate, and in that way make a certain amount of 
traction and force the plate away from the scar tissue. As shown 
in the x-my photograph, the foreign body was on the laryngeal 
side, the curvature fitting around the larynx. 

One of the peculiarities of the case was that the patient had 
not suffered from any laryngeal symptoms, and it would seem im- 
possible to have a foreign body of such size imbedded in the 
esophagus and against the trachea without producing any respira- 
tory symptoms. In the early history of the foreign body the 
patient complained of some soreness in his throat, although he 
never suffered any severe pain and never any difficulty in breath- 
ing. There was slight alteration in his voice, due more to inter- 
ference with the muscles of phonation than to the inflammatory 
action. The esophageal muscles, having been put on tension for 
so many months and years, had lost their muscular elasticity, and 
the inability of the patient to swallow after the removal of the 
foreign body was due more to this than it was due to the amount 
of scar tissue. 

Three months after the removal of the foreign body the esoph- 
ageal muscles had increased considerably in their action, and the 
patient was able to take semisolid food. 

I think the successful removal of this foreign body was due 
largely to the fact that I proceeded slowly and made as little 
trauma as possible in the esophageal structures, and by loosening 
the foreign body from its fibrous bed, by setting up slight inflam- 
matory action and then waiting a few days, I was enabled to re- 
move the plate without much laceration of the structures. 

In the majority of instances, with the aid of the esophagoscope, 
it apparently would not be difficult to locate a foreign body in the 
esophagus. But in the case described above, where the foreign 
body had been imbedded for eighteen years, the local conditions 
were so entirely different from those produced by a recent foreign 
body that the entire procedure was different. The granulation 
tissue which had organized into fibrous tissue, the imbedding of 
the foreign body in this tissue, together with the curvature of the 
spine, as shown in the a>ray (Fig. 247), rendered it exceedingly 
difficult to locate the foreign body in spite of its size and shape. 
The age of the patient and his generally poor condition were also 
important factors in this particular case. 



726 



DISEASES OF THE LARYNX. 

3 




>^53^ii^^^^^sT 




Fig. 248.— Schema illustrating upper tracheobronchoscopy (Chevalier Jackson) : A, 
Separable speculum in position ; B, bronchoscope passed through separable speculum ; 
C, slide of speculum removed ; D, separable speculum removed, leaving bronchoscope in 
position. 



BRONCHOSCOPY. 



727 



" The author finds the Kahler instrument, shown in Fig. 249, 
an excellent one. One of the advantages is that there is no danger 
from the breaking of the small glass bulb at the end of the tube, 
the light being reflected from above. 




Fig. 249.— Kahler's esophagoscope. 



" Direct laryngoscopy is the first step of the procedure 
known as superior bronchoscopy. When the speculum is in this 
position (A, Fig. 248), the larynx and upper orifice of the esoph- 
agus are open for inspection or the removal of growths, speci- 
mens, or foreign bodies, and the incision of edematous swellings. 
These and other endolaryngeal manipulations are done with an 
accuracy possible in no other way. 

" When it is desired to perform direct laryngoscopy under local 
anesthesia a more advantageous leverage is necessary to overcome 
the muscular resistance. This is afforded by the extra handle 
(A, B, Fig. 242). The pharynx and larynx are first cocainized 
with cotton mops held in the Sajous forceps (J, Fig. 242), using the 
laryngoscopic mirror if desired. For the pharynx a 4 per cent, 
solution is sufficient, but in the larynx a 20 per cent, solution is 
necessary. The patient is placed in a sitting posture, the handle 
of the speculum is grasped in the right hand, and the epiglottis 
brought into view as before described, and it is again cocainized if 
necessary. It is then pulled anteriorly along with the tissues 
anterior to it, while the head is extended until the larynx comes 
into view (Fig. 243). 

" Considerable practice is necessary in acquiring the knack of 
exposing the larynx and of introducing tubes through the larynx 
into the trachea and bronchi. General anesthesia renders these 
manipulations, as well as those of esophagoscopy, very much easier. 
The manipulations should be practised upon the dog and the 
cadaver. 

" 1,0 wer bronchoscopy is readily practised. The tube is 
introduced through a tracheotomy wound and the trachea and 
bronchi are explored." . . 



728 DISEASES OF THE LARYNX. 



FOREIGN BODIES IN THE LARYNX. 

The entrance of foreign bodies into the larynx or air-passages 
below is an accident, as a rule, attended with the gravest danger. 
The bodies may enter during the acts of chewing, swallowing, 
breathing, or speaking, and the severity of the symptoms depends 
to a great extent upon their size, character, and location. 

The bodies which may find lodgement in the air-passages may 
be divided into fluid and solid. The fluids comprise articles of 
liquid food, the contents of abscesses in the tonsillar or retro- 
pharyngeal region, blood that may enter the larynx during sur- 
gical operations, and vomited matter. Abnormal or diseased 
conditions of the throat or larynx, causing anesthesia, fistulous 
openings between the respiratory and alimentary tracts, stricture 
of the esophagus, causing regurgitation of food, act as predispos- 
ing factors toward entrance into the larynx of extraneous matter. 
The variety of solid bodies may be divided into animate and 
inanimate, and vary so much in size, consistency, and shape that 
it would be impossible to give a complete enumeration of them. 
Children occasionally fall asleep with various substances in their 
mouths, which in this Avay are very liable to make their way into 
the air-passages. Foreign bodies usually enter through the mouth, 
but there are instances in which a diseased bronchial gland has 
forced its way into the lung-structure, or a broken-down gland has 
stopped up a bronchus by its cheesy degeneration. 

Symptoms. — It is rare for a foreign body to effect an entrance 
into the air-passages without the individual being aware of the 
accident. In the great majority of cases the presence of the body 
makes itself known by a series of alarming symptoms. The 
patient suddenly commences to choke or gasp for breath, the 
dyspnea being usually of an inspiratory character. There is great 
alarm, with anxiety and restlessness. The eyes protrude, and in 
the severer cases the face becomes congested from defective oxy- 
genation. These symptoms may finally terminate in death, or 
they may gradually subside, and respiration that is almost normal 
may set in, with, however, a history of recurrence of these attacks, 
dependent either on the change in position of the patient or the 
character and location of the foreign body. If the body be angu- 
lar, sharp, or pointed, there will, as a rule, be symptoms of greater 
gravity than when the foreign substance is smooth and unirritating. 
In the severer cases, emphysema of the neck and upper portion 
of the chest may occur, due to the rupture of some portion of the 
air-passages. Hemorrhage may result, due to the erosion of the 
membrane by the movable body during respiration, or on attempted 
ejection by the patient or removal by the physician. A spasmodic, 
hoarse cough, with loss of voice, may be noticed. In some in- 
stances the cough may be croupy in character, closely resembling 






FOREIGN BODIES IN THE LARYNX. 729 

that of whooping cough. The more remote effects of the presence 
of a foreign body upon the upper respiratory tract may be reac- 
tionary inflammation and ulceration. According to its location, 
" laryngitis with edema, inflammation or ulceration of the trachea 
or bronchi, emphysema, pneumonia, pleurisy, abscess of the lungs, 
abscess of the larynx followed by necrosis of the cartilages either 
of the larynx or trachea, may result." 

Diagnosis. — Usually, the diagnosis of the presence of a for- 
eign body in the larynx or its continuation is not attended with 
difficulty, as the history of the case and inspection, if it be pos- 
sible, or palpation, are sufficient to establish a diagnosis. Foreign 
bodies in the esophagus may give rise to symptoms much the same 
as if the body was in the larynx. As a rule, when the foreign 
body is in the esophagus all the symptoms are aggravated, 
and the tendency to dyspnea increased when the recumbent 
position is assumed. Difficulty of diagnosis, however, may 
arise if the body be inspired during sleep, during an epi- 
leptic seizure, or at the moment of receiving an injury or blow, 
when the effects may be attributed solely to the accident or 
attack and the presence of the body overlooked. In locating a 
body that has passed into the bronchi, the anatomical structure of 
this locality should be borne in mind ; and it should be remem- 
bered that more often the substance will find lodgement in the 
right bronchus or its bifurcation than in the left, because the 
right bronchus is located higher up than the left. Auscultation 
may reveal peculiar harsh or sonorous rales at the location of the 
substance. Cohen notes that obstruction of the left bronchus 
causes an absence of respiratory murmur over the entire lung ; 
while occlusion of the right bronchus usually produces absence of 
the respiratory murmur over the lower lobe alone of that side, the 
division of the latter bronchus being nearer the bifurcation. The 
body may be located by the use of the tongue-depressor alone, if 
it be situated high up in the larynx or in the laryngopharynx. 
Failing in this, the laryngoscopical mirror may be employed, 
although an examination of such a character is exceedingly diffi- 
cult at any time, either during the acute attack, because of the 
danger of increasing the dyspnea, or during the interval, because of 
the hypersensitiveness usually existing. The palpating finger may 
locate a body in the larynx when the examination with the mir- 
ror is impossible. The differential diagnosis between pulmonary 
phthisis and foreign body of long standing in one of the bronchi 
is a matter of exceeding difficulty. The one-sided bronchitis, 
which recurs, the mucopurulent expectoration tinged, perhaps, 
with blood, and the inability to discover the tubercle bacillus in 
the sputum may be of aid. 

Prognosis. — The outlook in all cases of foreign body in the 
larynx, irrespective of position or regardless of removal, should 



730 DISEASES OF THE LARYNX. 

be exceedingly grave. Expulsion of the body by the effects of 
nature may occur at once or at any time subsequent, as cases where 
it has remained in position from one day to sixty years have been 
reported in which unaided expulsion of the body has occurred. 
Effort should be made, however, to extract the body at the earliest 
possible opportunity, as there is no doubt but that, even if opera- 
tive interference is at length imperative, the danger to life is not 
proportionately increased. 

Treatment.^After the acuteness of the spasm of choking 
has subsided, effort should be made, by the methods given, to 
ascertain the position and character of the offending body. If, 
however, the dyspnea does not abate and seems to threaten life, 
operative interference should be instituted at once. The admin- 
istration of sternutatories and emetics should be avoided. No 
attempt should be made in the great majority of cases at volun- 
tary efforts at expulsion by the patient, especially if the body is 
irregularly shaped, sharp, or angular, as there would be danger of 
further embedding it in the structure. The patient should be 
inverted or placed on his back on a table, with the shoulders 
drawn to the edge, so that the head hangs over it ; in this way 
the danger of the body falling still further into the larynx during 
the attempt at removal is obviated, breathing is rendered freer, 
and examination is much easier. If the exact position of the 
body can be located either with the mirror or palpating finger, it 
may be grasped by the curved laryngeal forceps and its removal 
effected. Inversion alone sometimes succeeds in freeing the body,- 
especially if it be round or smooth. Should all of these methods 
fail, recourse should be had to tracheotomy, the position of the 
operation depending on the location of the body. Not infrequently 
after tracheotomy the body, if located below, may be expelled through 
the artificial opening, or may be forced up so that it can be grasped 
and removed. Should this not occur, the patient's body should be 
shaken or the inverted position assumed, with the hope of bring- 
ing the offending substance within reach of instrumentation. If 
it be impossible at the time of operation to locate the body, the 
edges of the trachea may be stitched to the integument and the 
wound left open for further search. The introduction of a small 
mirror may assist in locating the body. Blowing strongly into the 
trachea may assist in expulsion by the reactionary expiration, or 
the artificial production of cough by a feather may be also of use 
in dislodgement. 

PROLAPSE OF THE LARYNGEAL VENTRICLES (EVERSION OF 
THE VENTRICLES OF THE LARYNX). 

The freeing of the mucous lining of the ventricles of the larynx 
from its attachment, followed by a pouching or eversion of this 
tissue, encroaching upon the cavity of the larynx, is an unusual 



PROLAPSE OF THE LARYNGEAL VENTRICLES. 731 

occurrence, and rarely diagnosticated during life. Persons in 
whom this condition has been observed have been afflicted with 
either tuberculosis or syphilis, a fact which may or may not bear a 
causal relation to the affection. During a violent fit of coughing 
the relaxed mucous membrane may be torn from its attachment 
and bulge out into the lumen of the larynx. The symptoms 
caused by the existence of these rounded, soft, smooth tumors, 
pale pink, somewhat injected, lying on the cord, apparently arising 
from the ventricular fissure, may be so slight as not to be noticed, 
or may consist in dyspnea varying in intensity with the size of the 
mass. From malignant growth, the absence of ulceration, con- 
sidering the length of time the symptoms have existed, with lack 
of glandular involvement, easily differentiates the affection. The 
density of a fibroid, its irregular nodulation, coupled with the fact 
that it never springs from the ventricles, are the main points to be 
considered in differentiating it from a prolapse of the ventricle. 
This prolapse may occur in the very young, and may cause alarm- 
ing symptoms owing to the obstruction to breathing. In one case 
in a very young child, which came under my observation, the 
dyspnea was quite marked and on several occasions after coughing 
the little patient was markedly cyanosed. 

The hernia-like protrusion cannot be replaced with any likeli- 
hood of its remaining in position. Astringent applications of 
chromic acid may have some effect in reducing the size of the ever- 
sion. Ablation of the prolapsed tissue with the snare or cutting 
forceps (Fig. 73), either through the natural passages or following 
thyrotomy, has been successfully effected. 



CHAPTER XX. 

VOICE AND SPEECH. 

Voice : 

Production of; 

Character of; 

Phonation ; 

Articulation ; 

Pronunciation ; 

Acoustics ; 

Kelation of Voice to Hearing. 

Speech, Defects of: 

Aprosexia; Aphonia; Aphasia; 
Aphthongia ; Echolalia ; Dyslalia ; 
Lallation ; Balbuties ; Psellism ; 
Mogilalia; Lisping; Anarthria; 
Alalia; Laloplegia; Lalopathy; 
Stammering; Stuttering; Pseudokousma ; 
Diplocusis ; Mutation ; Deaf-mutism ; 
Feeble-mindedness ; Word-blindness. 



VOICE. 

In the production of voice two distinct mechanisms are em- 
ployed : the vocal and the respiratory. The same is true in the 
production of sound, although sound is not necessarily voice, but 
voice is sound. These two mechanisms can be worked indepen- 
dently of each other, but to produce voice aud sound must be used 
jointly. To convert voice into speech, another independent mech- 
anism is employed, the articulating mechanism, and with the artic- 
ulating mechanism comes the acoustics, the resonating tube, and 
the quality and volume of tone. 

One throat resembles another, and in giving out the harshest 
sounds the muscles, vocal cords, and cartilages develop the 
same activity as in producing the most enchanting tones. 

The educated or the uneducated may alike have pleasing or 
displeasing voices. The talented individual may be able to express 
fluently his thoughts and ideas in written language, yet when the 
same is expressed through the medium of speech, owing to his 
disagreeable, rasping voice and faulty delivery, much of the mean- 
ing of the thought is lost. 

The voice peculiar to different nationalities can be explained in 
a number of ways. Climatic conditions and environments un- 
doubtedly influence not the production of voice, but its quality 
and tone. Facial contour peculiar to races would necessarily 

732 



VOICE. 733 

imply different resonating tubes, and different acoustic properties ; 
consequently, different voice. The different climatic conditions of 
various countries also affect the mucous membrane of the upper 
respiratory tract, and in return influence voice production, espe- 
cially quality, pitch, and tone. 

The range of sound of the human voice is from two and a half 
to three octaves ; less in most voices, more in some rare instances. 
The extreme limit of the human voice is said to be F, which has 
43J vibrations per second. 

The modification of pitch is chiefly effected by progressive 
variation in tension of membranous bands, variation in shape of 
the glottis, and the muscular structure of the larynx. This is 
supplemented by variations in position and shape of the walls of 
the larynx, windpipe, pharynx, mouth, and accessory cavities. 
The force of the current of air will likewise affect the pitch to 
a certain extent. When the laryngeal muscles, extrinsic and in- 
trinsic, stretch the vocal cords, increasing their tension, the pitch 
ascends ; and when the muscles are relaxed so that tension is 
diminished, the pitch falls. 

The physical laws that preside over the production of the 
human voice do not differ in any particular from the physical laws 
governing the production of sound from any other source. With- 
out hearing, however, there is no sound. 

Sounds, vocal and otherwise, differ in three important charac- 
teristics : Intensity, pitch, and quality. 

Intensity of tone is due to the extent of the vibration to and 
fro, consequently to the size of the sound-waves or undulations 
in the atmosphere, and is controlled by objective and subjective 
hearing or sound perception. Now, bodies vibrating in larger ex- 
cursion to and fro from their point of rest set larger masses of air 
in motion than when that excursion is more limited, and the 
greater the extent to which the disturbance in the air reaches, 
the louder the sound. If we pull lightly upon the cord of 
a piano, it will vibrate but a short distance to and fro, and the 
sound will be feeble, but if we pull it more forcibly it will move 
over a greater space and the sound will be louder because a 
greater mass of air is set in motion and larger waves of sound 
are generated in consequence. The same thing takes place in the 
human voice. If the vocal cords are only moderately tense, they 
can move over a larger extent of space than when they are held 
more tense. Hence, the sound is louder and the sound-waves 
being larger, they are felt in certain portions of the scale as they 
strike the walls of the wind-pipe, bronchial tubes, and air-cells of 
the lungs and resonator, producing that peculiar vibration of the 
chest-walls which has given rise to the denomination of chest-tones 
in the lower portion of the vocal register. The intensity of the 
voice depends upon the force of impact of the escaping current of 



734 VOICE AND SPEECH. 

air and upon the elasticity and regularity of the vocal bands and 
resonator. 

Pitch is the degree of acuteness or intonation, or the position 
of sound in the musical scale, and is independent of intensity or 
quality. 

Quality (timbre, tone-character) is that peculiarity by which 
the sound of any one instrument or one voice is distinguished 
from other instruments or other voices, and is independent of in- 
tensity or pitch. Quality, or timbre, results from the harmonious 
commixture of a fundamental or ground-tone and its overtones 
and their combinations. The delicacy or shade of the clang of the 
tone varies with the number of these overtones, their position in 
the musical scale, and their relative intensity as maintained during 
the continuance of the tone. 

Voice is sound (but all sound is not necessarily voice) originated 
in the larynx, and may be produced by any animal possessing that 
organ. 

Speaking is voice modified in the cavity of the mouth and sup- 
ported by cerebration. 

Singing is a higher development of the same power, being, in 
fact, sustained musical speaking. 

Makuen defines voice as " a moving column of breath set in 
vibration by its own impact with the vocal bands and reinforced 
by its diffusion through the various resonations into the surround- 
ing atmosphere." He also defines speech as " an articulated 
voice." 

The quality of a tone depends, physically, upon the shape or 
composite conformation of the series of undulatory waves of 
sound which collectively produce it, and this production depends 
on the shape and conformation of the respiratory tract. 

Reach, or carrying quality of the individual voice, is the pen- 
etrating power of a sound over distance and obstacles, such as 
other sounds, and is due to the purity of the tone, which, in its 
turn, is dependent on the accuracy with which it is produced. 

The shape of the resonant apparatus (cavities of the throat, 
mouth, and nasal passages) has great influence on the quality of 
the voice. Alterations of configuration by disease impair the 
voice, and alterations of shape by design modify it. 

Four chief varieties of voice are recognized in vocal and 
musical utterance : two in the voice of the male, and two in that 
of the female. The human voice has a compass of about two or 
three octaves, and is divided into soprano, alto (contralto), tenor 
and bass ; or soprano, mezzo-soprano, alto, tenor, baritone, and 
bass. A baritone voice is a tenor voice possessing but a mod- 
erate compass in the higher scale, and yet incapable of going very 
low ; and mezzo-soprano is a soprano voice in the same rela- 
tive condition. This diversity is caused by the construction of the 



VOICE. 735 

vocal organs and resonating tube, and is largely controlled by 
nationality. The cords of women and children are shorter, and 
therefore their voices are higher and finer than those of men. 

The mutation of the voice is the period of development of the 
boy to manhood, and girl to womanhood. In this period the com- 
pass varies. 

Two distinct mechanisms are necessary for the production of 
voice. For the conversion of voice into speech there is associated 
the independent mechanism, that of articulation. 

The vocal sound is produced by the vibration of the vocal 
cords, but is modified and executed by the adjoining cavities ; 
namely, the chest, trachea, larynx, pharynx, nose and accessory 
sinuses, mouth, and tongue, known as resonations of the voice. 
The strength of the voice depends upon the force of the cur- 
rent of air expelled from the lungs, while the pitch depends 
largely upon the size of the vocal cords. Before puberty the 
voice is similar in both sexes ; as adolescence approaches, there is 
a change in the shape and size of the larynx and entire resonating 
-tube, which in the male is more marked and accompanied by a 
lowering of the pitch of the voice, due to increase in length and 
thickness of the vocal bands. 

The voice is produced by the air contained in the lungs pass- 
ing through the larynx, and thereby inducing sounding vibra- 
tions of the vocal cords, supported by a central impulse. 

The force of the voice depends on the condition of the organs 
of respiration, the chest, lungs, and larynx, but its metal de- 
pends on the condition of the mucous membrane that covers the 
larynx as well as all air-passages. 

The timbre (the real tone quality) is the peculiar, variable char- 
acter which everything that is spoken or sung, every tone regis- 
ter, every tone, apart from its intensity, can assume as soon as the 
sound produced in the larynx has entered into the pharynx. 

Makuen states that " up to a certain degree the production of 
every tone requires tension and closure of the vocal cords, and 
if but one of the muscles be utterly disabled, no perfect tone pro- 
duction whatever is possible." 

Guttman correctly states that " man can produce different 
kinds of tone, according to the way he allows the air to pass 
from his lungs, by more or less stretched vocal cords." 

While there is a conscious or unconscious mental impulse 
which starts the current which controls the intrinsic and extrinsic 
muscles of the larynx and sets in motion all the mechanism of 
tone and voice production, this implies a cerebral center ; yet, 
curiously enough, in certain diseases of the brain the voice is un- 
altered. In some forms of insanity the voice is still melodious, 
and the individual can sing and has not in any way lost the musi- 
cal qualities or expression of his voice, neither has he lost the art 



736 VOICE AND SPEECH. 

of singing with all its qualifications and modulations, while in 
other forms of insanity this faculty is lost. 

It is of no material advantage for a singer to have an especial 
knowledge of vocal physiology. Here, as everywhere, art has 
outstripped science by thousands of years, and is able to reach its 
utmost height without a suspicion of the manner of the achieve- 
ment. " He whom nature has endowed with the gift of song can 
sing as well as he who has a mouth can eat, without having 
learned%ow it is done." On the other hand, the less gifted will 
not become great singers, even with the most profound physio- 
logical studies and prolonged training by expert teachers. 

The brain and intellectual centers, the speech center, and 
thought, all work together in harmonious unison in this wonderful 
mechanism which is known as speech 'production. The stimulation 
to thought, the production of thought, the mental activity of the 
brain cells to create the impulse to be transmitted to the mechan- 
ism of phonation, the stimulation of the respiratory, the vocal, 
and the nerve centers, all instantly transmitted to set in motion 
that completed and wonderful mechanism which produces sound 
and speech. 

Acoustics of the mouth and the relation of the voice to hear- 
ing brings up a number of interesting features. Certainly, voice, 
speech, and hearing are intimately connected. 

ACOUSTICS. 

Much has been written from a physiological standpoint con- 
cerning the speaking and singing voice. Such writers and inves- 
tigators as Mueller, Helmholtz, Gradenigo, Hcnsen, Gruber, 
Bezold, Spear, Bonnier, Rossback, Merkel, Cohen, Makuen, and 
Mackenzie have added much to our knowledge of the mechan- 
ism of phonation and hearing. Yet, after all, while a thorough 
knowledge of the normal condition is essential, the various methods 
used in training the voice are necessitated by pathologic alteration 
involving some portion of the speaking tract. 

The normal condition would only require training in executing, 
while the pathologic condition causes straining in execution. The 
anatomy and physiology is, of course, important, yet if all the 
tissues and parts were normally formed there would be little diffi- 
culty in training the human voice, but in the majority of cases 
there is some deviation from the normal which interferes with the 
regular mechanism of the apparatus of phonation. It is with 
these irregularities or pathologic conditions that we purpose to 
deal. It is of the greatest importance that the teachers of elo- 
cution and music should thoroughly understand these irregulari- 
ties and the very fact that different teachers strongly and urgently 
uphold different methods proves the existence of such irregulari- 



ACOUSTICS. 737 

ties. If the formation of the vocal apparatus was always normal 
there would be no necessity for methods. This explains why some 
methods are successful in some individuals and failures in others. 

The method, then, should be adapted to the individual case, 
and not the individual case to the method. The use of the facial 
muscles in a variation of tone is merely the power to expand the 
walls of the building, increase the volume, and lessen the resist- 
ance of tone. The power to depress the tongue and throw it 
in any position desired voluntarily lowers the floor of the build- 
ing, increases the space of outlet, and enables the individual to 
have a larger compass of voice. 

Voice production requires the use of a complicated mechanism, 
L e., the so-called musical ear. Through conscious or unconscious 
cerebration there are called into action for voice production three 
anatomical factors — the lungs, the larynx, and the resonance tube. 
The resonance tube includes all structures above the vocal cords, 
which includes the vestibule of the larynx. The pharynx, the 
tonsils, the posterior nares, the anterior nasal cavities, the acces- 
sory sinuses, especially the antrum of Highmore, and the mouth. 
It is this resonance tube that, after tone is produced, modifies or 
aids the fulness, the smoothness, the roundness, the power, the 
sweetness, and beauty of the voice. It is in this tube that the 
sounds produced in the larynx are reinforced, and it is in this 
same resonating tube that these sounds may be distorted and con- 
verted into rasping, disagreeable tones. 

Now, if the three essential anatomical factors, namely, the 
lungs, larynx, and resonating tube, are proportionate, then the 
tones coming from the larynx, being modified by the perfect reson- 
ator, unite and modify each other. If, however, there is any dis- 
proportion, this resonator acts as a distorter of sounds. It is like 
a tenor string on a bass violin, it is a misfit. If all parts 
work harmoniously, that individual is gifted with a natural voice 
and is a natural singer, requiring only careful education and prac- 
tice to make perfect execution ; but when such harmony does not 
exist, where diseased conditions or imperfectly developed parts in 
the voice apparatus do exist, it is then that the teacher of music 
must differentiate the condition, as one will require a method and 
the other merely execution. 

Volume, tone, and timbre are controlled by the size of the 
lungs, the larynx, and the resonance tube. Their loss, then, may 
result from (1) disease of the lungs, bronchi, or trachea ; (2) the 
larynx, with its innervation, not only local lesions, but lesions 
elsewhere ; (3) diseases of the pharynx and tonsils ; (4) diseases of 
the nose, including septum and antrum. 

Each voice has its individuality ; in fact our voice is a part 
of our individuality. Tone production, timbre, or quality and re- 
sonance together with execution do not repeat themselves in the 

47 



738 VOICE AND SPEECH. 

same manner in two individuals. This is especially marked in 
singers. 

As to the question, then, of the acoustics of the mouth in its 
relation to the voice, the upper part of the resonating tube — the 
mouth, the tongue, the hard and soft palate, nasopharynx, nos- 
trils, and accessory cavities bear the same relation to the voice as 
the building does to the speaker. The voice may be produced cor- 
rectly, but its quality lost in faulty acoustics. 

The building may be beautiful architecturally, but its acoustic 
properties poor. The decorator may improve the acoustics of 
the building ; so may the laryngologist and rhinologist improve the 
acoustics of the mouth by correcting faulty conditions that inter- 
fere with perfect resonance. For example, the removal of en- 
larged tonsils, nasopharyngeal growths, correction of nasal ob- 
struction, etc. Again, in some cases, certain pathological condi- 
tions may improve the acoustics. One of our famous singers has 
abnormally large tonsils, in fact so large that when the tongue is 
protruded and the muscles of the larynx made tense, the tonsils 
project so as to meet in the median line ; yet, when that individual 
sings, by depressing the tongue the tonsils fill into the lateral 
cavity of the pharynx, the patient having an unusually wide 
pharynx with concave Avails. In this position, then, the tonsils 
offer no obstruction to sound in the resonating tube, while the re- 
moval of these tonsils would entirely alter the walls of the build- 
ing, and would also alter its acoustic properties. 

An advantage of the mouth as a part of the resonating tube 
and its relation to acoustics is that the soft parts, namely, the 
cheeks and the tongue, can be placed in various positions at will, 
so that the walls of the building can be expanded or contracted 
and the floor of the building elevated or depressed at the will of 
the individual. 

The sensation of sound is due to a certain motion or tremor 
produced in the molecules of the extreme filaments of the nerve 
of hearing (see relation of voice and acoustics to hearing be- 
low), and vibrating synchronously or in unison with the sonor- 
ous body. The motions of the sounding body are transmitted in 
pulses or waves through the air, or whatever other medium it may 
be, into our ears, and thence along the nerve of hearing into the 
brain, by which it is perceived and interpreted, and upon which 
it makes the special impression which we designate sound. 

The relation of the voice to hearing and the control of 
the voice by hearing presents an interesting subject for discussion 
and study. Voice is not hearing ; we also have voice in the 
absence of hearing, yet hearing is really the controlling clement in 
the production of voice. The relation of our own hearing to our 
individual voices is illustrated in our speaking and singing. Our 
voice to us is what our ears indicate. 



ACOUSTICS. 739 

As to hearing, this necessitates two classifications, namely, 
subjective and objective hearing. By subjective hearing we mean 
the individual's subjective sense of sound-perception ; in various 
lesions of the ear with the various noises heard by the patient, 
that is subjective ; his sense of sound-perception of his own voice 
is subjective. However, in noises of the ear which are usually 
only heard by the patient, we can form no comparison, because 
the observer cannot hear the noise. As to his own voice, we 
can compare his subjective sense of sound-perception with that 
of the observer. The individual's subjective sense of sound-per- 
ception is determined purely by external sounds. As to whether 
this is normal or abnormal he can easily determine by comparison 
with the external objective sense of sound-perception of others. 

The training and cultivating of the voice under the guidance 
of a teacher, to be sure, is a great factor in the success of the 
individual as to his speaking or singing voice ; however, one of the 
greatest difficulties the instructor often has is to convince the 
pupil that his voice is wrong. The pupil's own ears tell him that 
it is right. Many probably are aware that one of our greatest 
singers has one note which to that individual's ears is in perfect 
harmony, but which in reality is one-half tone flat. 

A musical ear docs not mean a musical voice. Some individ- 
uals cannot sing or play and, as far as the music is concerned, 
could not tell "Yankee Doodle" from "Old Hundred ;" yet the 
slightest discord in the human or orchestral tones will be detected 
instantly by such a person's hearing. 

Again, certain individuals may have a musical voice as far 
as conversation or speaking is concerned ; I say musical, meaning 
a pleasing tone ; yet such individuals cannot sing, and their ear 
will not tell them whether they are in cord or discord. If, how- 
ever, they are attempting to sing with others their ear will tell 
them if the voices do not harmonize, yet they cannot control it, as 
their ear does not seem to indicate to them that fineness or distinc- 
tion of tone which permits of harmony. 

The alteration in the individual's voice where the hearing has 
become defective is so marked as to become almost characteristic, 
although there are exceptions to this. I have seen a number of 
cases in which the patient was so deaf that he could not hear con- 
versation even in the very loudest tones, yet there was practically 
no alteration in the voice, but this is, indeed, the exception. 

The deaf and dumb may be taught to speak, yet the voice pro- 
duced is unnatural and not altogether pleasing. The hearing, 
then, associated with the voice acts as a regulator ; defective hear- 
ing may mean altered voice. 

It often falls to the lot of the laryngologist to examine the 
throats of singers or would-be singers, and many times the instruc- 
tor of music, having used all his methods and means to train a 



740 VOICE AND SPEECH. 

certain voice, finally appeals to you to determine what is the 
matter. The pupil is thoroughly convinced that he can 
sing, and to his ear he can sing, but, unfortunately, to the 
nine hundred and ninety-nine listeners his subjective sense of 
sound-perception is faulty. These cases are, indeed, pitiful. 
I do not mean that we. do not have some cases ivho think 
they can sing in spite of their hearing and voice. These facts 
must be taken into consideration by the elocutionist and the 
teacher of music. 

Another extremely interesting fact illustrating the relation 
of the voice and hearing is this : in the first place, few of us could 
accurately describe our voices so that the voice would be recog- 
nized by any one else. Frequently w r e hear individuals discuss 
voices, either speaking or singing, and while seven out of ten 
might agree that the voice was pleasing, melodious, soft, and 
sympathetic, and possessed the many other attributes necessary in 
a successful singer, yet the remaining three of the ten would find 
fault, some rasping note, something not pleasing, showing that 
the objective sense of sound-perception varies greatly in individ- 
uals. Frequently individuals are criticised for their loud tone 
of voice. Individually they may be charming, but their loud 
tone of voice frequently attracts attention, yet this individual 
himself does not know that he is speaking in such a loud tone 
of voice. I know this is true, as I have interviewed sev- 
eral such persons, who had been taken to task for their loud 
tone of voice. When I would have them lower their voice to 
an ordinary pleasing conversational tone, they assured me that to 
them it sounded as though they were speaking scarcely above a 
whisper, showing that their ears for their own voice were not so 
sensitive as for outside sounds. In such individuals the subjec- 
tive sense of sound-perception was decreased or below normal, 
while their objective sense was normal. On the other hand, some 
individuals who use a quiet, soft, low tone of voice, to their own 
ear it sounds as if they were speaking in a very loud tone of 
voice. In such individuals their subjective sense of sound-per- 
ception is extremely sensitive or exaggerated. Just as objective 
sense to sound may vary, so does the subjective sense vary. 

The effect of drugs and stimulants also illustrates the peculiar 
relation of the individual's voice to hearing, in that certain 
drugs or stimulants may exaggerate the two conditions which I 
have just described. The man with the defective loud voice talks 
louder and the man with the defective low voice finally speaks so 
low that you can scarcely hear him. 

The jerky, irregular voice of deaf persons is another index or 
evidence of the peculiar relation of the voice and hearing. With- 
out hearing, of course, there is no sound, but the voice is more 
than sound, and the voice to the individual, or rather the individ- 



ACOUSTICS. 741 

ual's voice to himself, is exactly what his ear tells him it is, and if 
there is any loss of harmony between these two, then he will have 
defective voice, yet in response to all the tests of hearing he shows 
normal reaction. 

A few days ago, in training a young man, whose voice had not 
changed at puberty, and finally by the use of the falsetto voice I 
had worked him down to a perfectly natural tone, and after having 
him speak in that for one or a few minutes, his face assumed an 
anxious expression and he said, "Will that be my natural voice? 
for to me it sounds frightfully strange and unnatural." His ear 
had not been trained to that sound. 

Pathological alterations of the structures of the nasopharynx, 
whether due to local or systemic changes, will produce subjec- 
tive and objective alterations in the sound-perceiving apparatus. 
The objective one can be determined by tests, while the subjective 
ones can only be described by the individual. The tinnitus asso- 
ciated with any such alteration, no matter what form it may 
assume, is heard only by the individual, except in rare pulsating 
cases, and it cannot be detected by the observer, although fre- 
quently subjective sounds are so intense that the individual 
thus afflicted can scarcely realize that the sounds cannot be heard 
by the observer. 

The involvement of the apparatus of subjective sound-percep- 
tion, especially of the inner portion of the orifice of the 
Eustachian tube, will give to the patient the sensation of 
altered voice, common in singers. To the audience their voice is 
in perfect form, while to their own ear the voice sounds muffled ; 
in other words, the subjective perception is interfered with, while 
the voice is in perfect form. At the same time, this individual 
may not show any defective objective sound-perception. In objec- 
tive sound-perception the external ear is the collector of sound, 
while the drum-membrane and ossicles of the middle ear are the 
transmitters of sound ; in subjective hearing this condition is par- 
tially reversed, the Eustachian tube partially taking the place of 
the external ear. 

Sound is what we hear; our perception of sound depends 
upon whether it is subjective or objective, and our description of 
sound will depend upon the condition, subjective and objective, of 
our sound-perceiving apparatus. The deaf-mute has no conception 
of perception of either subjective or objective sounds. 

Voice is sound ; speech is voice in action ; the impression made 
by voice and speech will depend entirely upon the condition of the 
sound-perceiving apparatus ; to the individual himself it will be 
both subjective and objective, but to the listener it will be entirely 
objective. The impression given to either speaker or hearer 
will depend upon the acoustics of the mouth and the condition of 
the subjective and objective hearing of the individual. 



742 VOICE AND SPEECH. 

The objective sense of sound-perception in individuals varies 
in a number of ways. For example, the stringed instruments, as 
the violin, banjo, and guitar, as compared with the piano, give 
entirely different impressions to different individuals. 

Intellect is also a factor, but not an essential one. The most 
highly educated may not have the slightest objective sense of 
sound-perception as to music, while the ignorant and unedu- 
cated may have an extremely sensitive subjective and objective 
sense of sound-perception as to musical tone — the so-called 
" musical ear." 

" The normal child begins to understand spoken words during 
the closing months of the first year. If a child does not hear 
words spoken he will not understand them, and if he does not 
understand them he will not use them. In other words, he will 
not be able to associate ideas, words, and objects. There will 
be no development of speech, and, in consequence, no develop- 
ment of all that portion of the brain and nervous system which 
presides over the faculty of speech. The intellectual centers 
also, being deprived of the stimulus which comes from the use of 
spoken and written language, will share in the tardy development. 
The moral nature also becomes perverted." (Makuen.) 

To hear spoken words does not necessarily mean to understand 
them, but before a child can understand spoken words he certainly 
must hear them. He may gather impressions by means of 
motions and signs, but to fully comprehend there must be devel- 
oped speech and hearing and association of ideas. 

The possibility of improvement by any method in congenital 
deaf-mutism is very small. However, many supposedly deaf- 
mutes were born with some hearing power, or in the process of 
development the hearing mechanism was disturbed and practically 
cut off. If, however, the child did hear during the first few 
months or years of life, there have already been some mental im- 
pressions and conceptions of sound. These cases will respond to 
treatment better than the congenital deaf-mute. 

Makuen (G. Hudson), in speaking of this condition, says : u It 
is well known that even an adult person being partially deaf, from 
whatever cause, may become entirely so by lack of exercising the 
function of hearing, and this is especially true of children, be- 
cause never having experienced the advantages of acute hearing, 
they have no incentive to give attention to sounds that are not 
clearly audible to them. A child, therefore, may have a fair 
degree of hearing power and yet lose it from disuse. He does 
not hear enough of the conversation about him to attract his 
attention and to cause him to reflect upon it, and, therefore, 
he has no inducement to continue to listen, and there follows 
atrophy of the nerve-tracts leading to the auditory centers of 
the brain and a lack of development also of these centers them- 



ACOUSTICS. 743 

selves. There is no clear perception of sound, and there are no 
sound nor word memories stored up in the brain, upon which 
the development of speech depends. The primary object of the 
treatment, therefore, is to prevent the child having this feeble and 
inadequate hearing power from finally becoming a deaf-mute, 
with all the disadvantages accompanying this condition." 

The practical application of the treatment must necessarily 
vary with individual cases, but a few general principles are appli- 
cable to all. Of course, only those children having at least a 
remnant of hearing power may be regarded as suitable subjects, 
and the ingenuity of the physician is often taxed to the utmost in 
determining this point. Urban tschitsch found the use of musical 
instruments to be of value in making the diagnosis, and in one of 
my patients the piano furnished the only sound to which any 
response was given. Personally, I prefer the electric bell, which 
can be placed near the patient's chair and manipulated by an 
assistant in another room, by signal from myself and not 
observed by the patient. Every possible means should be 
employed to detect evidences of hearing, and all those children 
giving the slightest response to any sound whatsoever should 
receive the hearing exercises. My own practice has been to begin 
the exercises with sounds similar to those of which the patient has 
shown some appreciation. If it is the piano that has interested 
him, let the piano be played regularly in his presence every day 
for a while, and then gradually take up the sounds of the human 
voice and particularly those used in ordinary conversation, using 
the same pitch and register as given by the instrument. One 
child observed by me and reported gave no evidence at first of 
hearing or understanding a single word of speech. Even the 
word " mamma " had no significance to her. My plan was to 
point to her mother and at the same time speak the word distinctly 
and repeatedly in close approximation to the ear. It was found 
neither necessary nor desirable to speak in loud tones, but distinct- 
ness and a slight prolongation of the elements of the word 
seemed to give better results. Repetition is also an important 
factor in the procedure. If no indications of hearing the word 
are apparent, the hand of the patient should be placed over the 
mouth and larynx of the operator, in order to combine the sense 
of touch with that of hearing, and at the same time a mirror may 
be used to enable the patient to see the movements of the lips and 
lower jaw, also associated objects with the conversation. These 
procedures help to hold the attention of the child and to arouse in- 
terest in the work. An attempt is then made to have him pro- 
duce the sound as he perceives it through the channels of hearing, 
touch, and sight. It is not a difficult matter to teach even totally 
deaf children to speak and to understand speech through the 
senses of touch and sight, but the voice is always harsh and dis- 



744 VOICE AND SPEECH. 

agreeable. The sense of hearing is essential to the modulation of 
the voice, and this fact is of great diagnostic importance. It is a 
rule without exception that the " so-called " deaf-mute who learns 
to speak in modulated tones has some hearing power that may be 
improved by exercise. 

Teaching the child to speak is quite as important as teaching 
him to hear, and the one helps the other. It is probable that one 
never quite hears the sounds of speech accurately until he is able 
to reproduce them. In the use of aural gymnastics as a remedial 
measure great patience and skill are necessary. Not only must 
the teacher possess a knowledge of phonetics, but he must also 
know something of the child-nature and understand the child's 
point of view, in order that he may gain his confidence and enlist 
his co-operation. In other words, the teacher must be a keen 
student of human nature. 

Makuen's conclusions are as follows : 

16 First : The hearing of the deaf child may be greatly im- 
proved by the systematic use of oral gymnastics. 

" Second : The speaking voice used in close approximation to 
the ear is the most effective form of oral gymnastics for children. 

" Third : The training of speech should be carried on simul- 
taneously with the hearing exercises. 

" Fourth : The degree of success attained will depend largely 
upon the skill and patience of the teacher. " 

DEVELOPMENT OF SPEECH. 

In the development of speech three mechanisms are necessary : 
The auditory, the vocal, and the oral, each having a central and 
peripheral control. 

Speech is natural, yet all persons possessing the power of 
speech are not good speakers. Some are natural speakers, being 
endowed with all the requisites of a pleasing voice, penetrating, 
carrying qualities, in fact qualities to meet all requirements ; in 
other words, a natural speaker. 

There is the natural singer and the natural speaker ; there is 
also the individual who may cultivate these faculties to a point of 
perfection ; while there is a third variety whose voice does not 
seem to possess the qualities that permit of cultivation, either to 
perfect them in speaking or singing. 

Speech is the audible means of communicating to others the 
product of the mind. Speech ordinarily means voice and sound, 
yet thoughts can be conveyed by signs and symbols ; the deaf and 
dumb communicating by means of a series of signs, yet his 
thoughts are the product of the mind, but not communicated by 
voice or sound. Speech, then, is a physiological or normal func- 
tion. It becomes automatic and mechanical, yet at the same 



DEVELOPMENT OF SPEECH. 745 

time it is always normally physiologically responsive to voluntary 
effort. Hence, modulation, force, power, expression, timbre, and 
volume, as referred to tone, voice, and speech. 

The power of the individual to control the muscles of the 
lateral walls of the pharynx, and of the mouth and tongue, will 
enable him to alter the quality of his voice by mechanically 
changing the walls of the building, thereby changing the acoustics. 

Speech is easily imitated. Unconsciously we may find ourselves 
imitating another's voice and speech, his accent, his mannerisms. 
This is equally true whether it be a mannerism, a peculiarity, a 
defect, or a pleasing voice. Children frequently acquire defects 
of speech merely from mimicking or imitating those who have 
defects of speech. This may be done voluntarily or it may be in 
a manner unconsciously acquired and the habit formed. In the 
young this is more serious, they being more impressionable than 
those of adult life. 

This question of imitating or acquiring by absorption or exam- 
ple, as it were, in children is illustrated in the child whose 
environments are such that he is always hearing the ideal speech 
and language, both grammatically and rhetorically. Compare this 
child with another, whose environments are the opposite. The 
latter will later on have to remedy not only possibly a defect 
of speech, but an entire mental process. The one acquired 
mechanically the rhetorical and grammatically correct language, 
and his impressions are already formed ; the other has to undo the 
wrong impressions and form correct ones. 

The absence of self-consciousness is essential to good speaking. 
This is illustrated in the sensitive individual, who, when appear- 
ing in public, frequently loses the impressive faculty of speech 
which he otherwise possesses. In other words, his mental equilib- 
rium is disturbed by his self-consciousness. 

Self-consciousness in speaking is entirely different from the lack 
of confidence in speaking. The retiring individual may be a 
bit self-conscious at the outset of public speaking, but as soon as 
the interest in his subject overcomes self-consciousness the 
speaker is at once at ease. This self-consciousness is a mental 
process brought about by environment. 

The transmission of thought and ideas through the medium of 
speech is entirely different from the transmission of the same 
thoughts and ideas through written language. In written lan- 
guage the expression of the individual, his characteristics, the 
force of the speaker, his mannerisms, etc., are lost. Frequently 
the impressions conveyed by the above mean more to the listener 
than the actual words used. This is illustrated by listening to an 
address and afterward reading the same address in print. 

The organs of speech are first illustrated in the newborn by 
the cry of the child, showing the production of sound, but not 



746 VOICE AND SPEECH. 

voice or speech. Gradually various other sounds are developed, 
such as laughing and various meaningless babbling sounds, 
giving expressions of pleasure or dissatisfaction on the part of the 
child. It is the child's way of expressing its wants before the 
power of speech has been developed. While the child expresses 
its feelings by these unintelligible sounds, yet they are its mode of 
speech until the period of intelligent speech production is devel- 
oped. From the twelfth to the fourteenth month the period 
of echolalia, the transit from this to intelligent speech may be very 
difficult in some cases ; at this period there is much danger of 
faulty impressions. Sometimes during this transition stage the 
child loses somewhat the control of the process of speech, 
meaningless words are used, and the wrong word or name applied 
to objects. This, however, is not exactly a speech defect, but a 
lack of association of the objects and words, a lack of training ; 
in other words, the confusion of thoughts and objects and the 
failure of harmonious action and transmission from the cerebral 
centers, due to faulty impressions and associations. 

Speech and voice are the individual's stock in trade. " If he 
had the wisdom of Solomon and had not the powers of speech, it 
would avail him not." It is the means of communication, the 
method of acquiring knowledge and communicating thought. 
Hence the close mental and mechanical relation between central 
impulse and tone production. 

The effect of environments on speech development is illustrated 
in children who are subjected to the accent or brogue of vari- 
ous nationalities in nurses or attendants. The child rapidly 
acquires the various brogues and dialects. 

The quality and tone of the voice may be pleasing or other- 
wise, but the speech shows plainly the early environments of the 
individual. 

Various conditions of ill-health and disease seem to aifect the 
speech centers. Infectious diseases of childhood play an impor- 
tant part, and, through inflammatory changes and conditions due to 
toxic absorption, the nerve-centers of speech may be slightly in- 
volved and various forms of speech defect result. Shock, fright, 
injuries to the head, affecting the mental and physical condition 
and involving the sympathetic nervous system, may also be 
etiological factors. 

In the production of articulate speech the sound produced in 
the larynx is moulded by the lips, tongue, soft palate, and the 
muscles of the pharyngeal and buccal cavities. While the pitch 
of the voice is dependent upon the larynx, the peculiar individual 
character is due largely to the resonating tube above. 

While it is almost impossible to prove this statement, yet 
observation tends to warrant it that a child understands spoken 
language before it has the power of speech ; at least it under- 



DEVELOPMENT OF SPEECH. 747 

stands what is meant by certain sounds, whether it understands 
the import of the word or not. This would seem to prove 
that the cerebral speech center and the brain development as to 
thought-formation antedate the perfection of the power to put 
into execution the combined mechanism concerned in speech pro- 
duction. 

Language and thought are intimately related. To be sure, 
language may not show much thought, but intelligent language cer- 
tainly necessitates thought; yet thought can be expressed other 
than through the medium of language, either written or spoken, 
by means of symbols, signs, expressions, and motions. 

In normal speech there must be co-ordination of the vocal, the 
respiratory, and the articulating mechanism. The central impulse, 
let it be voluntary or involuntary, or mechanical, is found in cere- 
bration, and the starting impulse to set these mechanisms in 
motion must come from a common cerebral center. 

The continuous and even working of the mechanism of phon- 
ation, developing sound and voice, backed by the mental impulse, 
are essential to speech. Rather, they are essential factors in the 
production of speech. 

The palate, hard and soft, the tongue and buccal cavities, are 
important factors in enunciation. 

Of the twenty-three consonant sounds, only two, " m " and 
" n," can be given distinctly when the palate is intact, and even in 
these the resonance is somewhat deficient. The palate has to do 
with the formation of the resonating tube, which, to a great ex- 
tent, controls and modulates the voice. 

The purely vocal elements of speech, such as the vowel sounds, 
may be fairly well articulated when the palate is defective. It 
is the interference with the resonating tube (see chapter on Acous- 
tics of the Mouth) that renders these sounds scarcely recogniz- 
able. In the consonants, however, not only is articulation, but 
also the resonance, interfered with. 

In purely consonant sounds the tongue is an essential and con- 
spicuous factor. It is essential in the so-called placing of the tone, 
controlling the size and shape of the cavity by the rapid place- 
ment of the tongue (see Acoustics) in forming these sounds. 

Makuen, in his article in regard to the relation of the palate 
and tongue to speech, says : " It should be borne in mind that the 
consonant sounds are made by impeding the moving column of 
breath at certain points above the larynx, and the points at which 
the impediment takes place have been called the stop positions. 
These have been divided into the anterior, the middle, and the pos- 
terior stop positions. The anterior one is formed by the lips (in 
the articulation of the so-called labial sounds, p, b, m, wh, w), by 
the lower lip and the teeth (in the articulation of the labiodentals, 
f, v), and by the tip of the tongue and the teeth (in the articula- 



748 VOICE AND SPEECH. 

tion of the linguodentals, th', th") ; the middle one by the tongue 
and the hard palate (in the articulation of the anterior linguopal- 
atals, s, z, sh, zh, t, d, n, 1, r), and the posterior one by the dorsum 
of the tongue and the soft palate (in the articulation of the pos- 
terior linguopalatals, k, g, ng, h, y). For all these sounds requir- 
ing an impediment in the outgoing column of breath, whichever 
stop position may be used, it is necessary to have a free, normal 
palate. 

" The function of the palate in articulation, therefore, is twofold. 
In all those sounds in which it does not assist in the formation of 
the stop position, it serves as an obturator between the nose and 
the pharynx, completing the partition between these two cavities 
and compelling the out-going breath to pass through the particular 
stop position required for the sound. For instance, in the articu- 
lation of labials, labiodentals, and linguodentals, the sounding 
breath must pass through the anterior stop position and the palate 
serves to diverge it in this direction and to prevent it from passing 
through the nostrils. In a similar manner, when a hard palate is 
intact and the middle stop position is used, as in the enunciation 
of the linguopalatals, the sounding breath must pass through this 
constricted aperture and the function of the palate is to prevent it 
from passing upward through the nostrils. In the use of the pos- 
terior stop position which is formed by the junction of the velum 
palati and the dorsum of the tongue, the soft palate serves a double 
purpose. Its free border rises against the posterior pharyngeal 
wall, closing the avenue to the nostrils, and its anterior surface, 
acting in conjunction with the tongue, forms the stop position for 
the sound. In the enunciation of these posterior linguopalatal 
sounds a perforation of the hard palate would have little, if any, 
effect upon the articulation, but it would somewhat modify the 
vocal resonance. 

" It will be observed that the tongue and the palate act together 
in the processes of articulation and that the palate also serves to 
prevent the sounding breath from passing through the nostrils 
and to focus it upon the particular stop position that is being 
used." 

SPEECH DEFECTS. 

Under the general term Speech Defects are many varieties, the 
most common of which are Stammering and Stuttering. However, 
there are various forms, such as Aprosexia, a condition in which 
there is inability to fix the attention, the inattention being due to 
mental weakness or to defective hearing, often seen in chronic 
catarrh of the nose or of the nasopharynx ; Aphonia, loss of voice 
not due to a central lesion ; Aphasia, defect or loss of the power 
of expression by speech, writing, or signs ; Aphthongia, which is 
aphasia due to spasm of the speech muscles ; Echolalia, or the 



SPEECH DEFECTS. 749 

meaningless repetition by a patient of words addressed to him ; 
Dyslalia, an impairment of utterance with abnormality of the ex- 
ternal speech organs ; Lallation, which is a babbling, infantile form 
of speech; Balbuties, and Psellism, meaning the same as Stammer- 
ing ; Mogilalia, difficulty in speech ; Lisping, which is the substi- 
tution of the th sounds for s and z; Anarthria, inability to utter 
words distinctly ; Alalia, sl defect of, or lack of the power of 
speech, due to a local disease of the vocal organs ; Laloplegia, 
paralysis of the organs of speech ; Lalopathy, any disorder 
affecting the speech ; Pseudokousma, or that condition in which 
there is false perception of pitch ; Diplophonia, or Diphthongia, 
the production of double vocal sounds ; Diplocusis, a reduplication 
of the original note or noise, which may be heard in one or both 
ears ; Mutation, that period of development of the boy and youth, 
and the girl to womanhood, during which time the compass of the 
voice varies. 

In the early development of speech there are three essential 
mechanisms employed. These three are absolutely essential and 
any defect in one of the three may influence the total result. They 
are the auditory, the oral, and the vocal mechanisms. Controlling 
this is the central and peripheral stimulus. The psychic centers, 
to be sure, originally control the development of speech. 

Defects of speech may also have as a causal factor involvement 
of the accessory cavities, the phenomena being very much the 
same as in the adenoid vegetation, one of the irregularities due to 
faulty development. Any pressure, in fact, about the accessory 
cavities, produces a sort of mental hebetude. The same condition 
has been observed where growths pressed upon the lymphatic and 
blood supplies of the structures of the upper respiratory tract and 
resonator. 

A number of theories have been advanced as to cause, but from 
the different varieties of defects of speech and the different phases 
assumed by various varieties, it is probable that no one cause can 
be assigned. The psychical side of the question is particularly 
interesting and can be worked out largely only by theory and de- 
duction. Unquestionably, the will power and mental resolve have 
not much to do with it. Suggestion and various psychical methods 
fail to effect a cure. The involvement of the brain or nerve-cen- 
ters, or the lack of strength and willingness to co-ordinate the 
powers, are certainly factors. 

Defects of speech may arise from either subjective or objective 
causes. 

Of the first, those things that exist within the child's own 
organism, as (1) a defective hearing apparatus, (2) a defective 
speech apparatus, and (3) a defective psychic apparatus. 

The objective causes would include all those causes which 
would arise from the child's environment, as (1) bad hygiene, 
(2) atmosphere of excitement, impairing the nervous organization, 



750 VOICE AND SPEECH. 

and (3) faulty examples of speech given them by those in attend- 
ance (Makuen). 

Conditions producing change in voice are growths of 
larynx and cords ; laryngeal congestion ; tonsillitis ; voice fatigue ; 
neuromuscular, chronic bulbar paralysis ; acute rhinitis ; chronic 
hypertrophic rhinitis ; hypertrophy of turbinates ; deviation of 
septum ; spurs ; foreign bodies ; polypi and tumors ; cleft palate. 

Hearing to a great extent controls voice and song. This 
brings up the question of " Can the deaf be taught to hear?" 
Methods have been devised by which ideas can be conveyed to the 
deaf and dumb, and even a moderate degree of speech and under- 
standing, if not hearing, can be developed. 

Toynbee has produced excellent results by his so-called oral 
gymnastic method. This method has been modified and improved 
upon, and excellent results have been obtained. 

Any defect in production of speech may reversely affect the 
mental development. This is particularly true in children and 
the very young. The perfectness of speech, viz., elocution, is a 
matter of training and application, yet the individual who speaks 
with an unconsciousness as to his own voice is always the effective 
speaker and the best elocutionist. 

The importance of central brain mechanism of speech is fully 
realized in certain lesions of the brain in which there is patho- 
logical alteration of the brain tissue ; not only the centers as to 
thought and language, voice and speech, but the lack of the stim- 
ulating impulse due to the degenerated brain tissue, even if the 
transmitting nerve supply yet remain intact. The irregularities 
in speech and the faulty mechanism of the muscle action show 
clearly the faulty central impulse. In lesions in which these 
centers are not involved the speech will be unimpaired. When 
development of the faculty of speech is delayed, no matter what 
the, cause, there is usually a corresponding lack of functional 
activity in both the visual and auditory word centers. 

Makuen maintains that the dependence of the functional 
activity of these special centers and their related areas upon the 
use of the faculty of speech is so great that its lack of develop- 
ment due to mechanical obstruction in the peripheral organs has in 
some cases led to a diagnosis of imbecility and even idiocy. 
He cites a case in which he believed the patient's inability to use 
speech resulted in functional derangement of cerebration that was 
mistaken for incurable organic defects. This, I am quite certain, 
is true, and every physician of any experience or powers of 
observation has seen such cases. 

The so-called " backward children " nearly all have some speech 
defect, either in articulation, enunciation, or lip motion. Being 
of the sensitive type, they notice that their voice does not sound 
so pleasing as others, and, probably on account of such peculiarity, 



SPEECH DEFECTS. 751 

they become the butt of the class, and instead of the instructor 
giving them special attention they are rather pushed aside and are 
gradually led to believe that they are mentally inferior to their 
classmates. Children being markedly impressionable, this has a 
very deleterious effect on the development of the child, affecting 
interest in study and also tending to develop a disposition of secre- 
tiveness and retirement. 

The common age for defects of speech is from three to fifteen 
years. It is rarely ever acquired after this age except by imitation. 

Some defects of speech are due to congenital malformations, 
such as cleft palate, faulty nasopharynx, interfering with the res- 
onator ; malformation of the cartilages of the larynx, but rarely 
ever any malformation of the cords. 

Stammerers usually manifest a great amount of nervousness, 
although their nervous system is not necessarily below par, the 
nervousness being associated with speech more as a result of the 
attempt rather than as a cause. Heredity has little to do with 
stammering. It is association, not heredity. 

Stammering and stuttering are frequently used to mean the same 
defect of speech. Stammering is more the substitution of incorrect 
sounds for the proper ones, and is due to a lack of response in the 
vocal mechanism to the mechanical central stimulation and a lack 
of co-ordination between this and the articulating mechanism. Ac- 
quired or congenital conditions may be responsible for this lack of 
co-ordination in the vocal and respiratory muscles. 

As to etiology, heredity plays but little part in defects of 
speech. The cause for every defect of speech may be found to 
exist in a faulty action in the muscles of one or more of the vocal, 
respiratory, or articulating mechanisms or in a faulty co-ordination 
between the mechanisms themselves. 

The so-called heredity probably may be explained by the asso- 
ciation of the younger generation with the older, in which any de- 
fect exists, this being more one of imitation and environment than 
an actual mental process or defect. 

Speech itself being really an acquired faculty, — a faculty 
which, though natural and normal, is not present at birth, but is 
acquired from the first to the third year, — yet it cannot be inher- 
ited. So instead of inherited tendency, it is inherited environ- 
ments which may act as an etiological factor in causing speech 
defects. 

In another variety of stuttering not frequently seen (but it has 
been my privilege to observe one or two such cases), the stuttering 
was inarticulate and the patient went through a series of facial 
gymnastics and breath-puffs without any sound whatever, and 
finally succeeded in producing a tone which in itself was perfectly 
natural ; but the entire process of spasmodic stuttering took 
place before the tone production. 



752 VOICE AND SPEECH. 

However, stuttering and stammering, I think, are somewhat 
analagous to infection and contagion — one of degree more than 
actuality. 

The individual may be unusually bright, in good physical con- 
dition ; in fact, well developed physically and mentally. Some 
stammerers are exceptionally bright in their studies. Stammering 
may be brought about by local anatomical defects ; it may also be 
acquired by imitating. In some cases the stammerer is below par 
physically and mentally. 

Kussmaul defines stuttering as " an impairment of speech 
arising from the spasmodic action of the nerves." Under this he 
includes stammering and aphthongia, which is a peculiar form of 
aphasia due to the spasm of the muscles supplied by the hypo- 
glossal nerve. 

Mechanical defects of speech, from the position of the body, 
are also interesting phenomena. The condition in which, 
owing to the muscular tension and pressure exercised by stoop- 
ing, or owing to faulty development of tissues or anomalous place- 
ment of the nerves, the mechanism of speech fails to work. This 
is illustrated in the condition described by Wyllie, known as the 
" drawback phonation." 

In some pathological cases (bilateral nodules) diplophonia is 
sometimes found. Flatau records a case in which this phenomenon 
could be produced voluntarily. The singer was of Hungarian 
nationality. 

The change of the voice at puberty sometimes goes on im- 
properly, and the young man acquires a high, falsetto tone instead 
of the regular tenor or bass. 

An examination of the larynx in such a condition shows the 
vocal cords to be excessively shiny and white, and apparently very 
tightly stretched. An external examination shows that in speak- 
ing or singing the larynx is pulled high up under the tongue, and 
often rather forward toward the chin. The condition is evidently 
due to over-contraction of both the intrinsic and the extrinsic 
muscles of the larynx, whereby the vocal cords are stretched too 
tightly. The over-contraction is found only during singing and 
speaking. 

The treatment begins by teaching the person to sing in very 
low tones. At first the tones will be harsh and rattling, but they 
will gradually become natural. The pitch of the song is gradually 
raised until the patient sings over the normal range of voice. 
Another exercise consists of chanting sentences on a single low 
tone, which is gradually raised in pitch in successive exercises. A 
third exercise consists in singing the first word or two of a sen- 
tence in a low tone, and finishing it by speaking. In a fourth line 
of work exercises in singing and speaking are used while the 
patient presses the larynx down and backward by putting his 



SPEECH DEFECTS. 753 

fingers on the hyoid bone and on the notch at the front of the 
thyroid cartilage. With such direct methods of treatment it is 
possible to eliminate the defect entirely, usually in a very short 
time. The cure is often completed in one or two weeks. 

Another curious fact about voice and speech is that anyone 
with good imitative powers can illustrate and imitate any known 
defect of speech from the asthmatic voice to the worst form of 
stammering. 

Peculiarities in manner of speech are mannerisms (like local- 
isms) on the part of individuals, more than peculiarities of speech, 
and must not be confounded with defects of speech. This is illus- 
trated in the gesticulatory utterances of certain individuals and 
nationalities. 

Another peculiar defect of speech is shown in persons who are 
overworked, mentally tired, and overtaxed physically, or the long- 
continued application to one line of work. They will mechanically 
reverse words and use words with no particular meaning or rela- 
tion to the subject discussed. This is not due to any defect in the 
mechanical mechanism of speech, but it is a break in the central 
impulse. Under stimulation or excitement this would not occur, 
but the fatigued brain will not respond regularly under the 
normal impulse. This is perfectly reasonable, as the same thing 
occurs in muscular tissue, in the secreting apparatuses, in hearing, 
and in the eye, etc. 

Lisping is one of the difficult forms of defects of speech to 
correct. Frequently the patient does not perceive that he does 
lisp. The defect is one of articulation, and has nothing to do 
with tone production ; it is rather execution of tone than pro- 
duction of tone. The important factor is the prevention of lisp- 
ing by correct teaching in childhood. This form of defect of 
speech is frequently acquired, especially in early childhood, by 
imitation, either consciously or unconsciously. When due to 
" tongue-tie," the treatment is self-evident. 

Paralysis ^>r paretic conditions involving the nerve supply to 
certain structures, especially the tongue, the palate, or the lips, 
are mechanical causes of defects of speech. There is nothing 
wrong with the speech center or the transmission, but merely 
in the mechanical execution of the structures concerned in voice 
or tone production. 

Defects of speech may be associated with forms of paralysis, 
not only of the vocal cords but of the medulla, involving the 
co-ordinate centers and lesions which involve the brain-center. 

The defect of speech may be mechanical or may be due to in- 
volvement of the nerve supply ; or it may be due to interference 
with function by pathological lesions or growths. 

Bastin defines " Word-blindness" as " a condition due to the fact 
that the visual word center is either congenitallv weak or else 

48 



754 VOICE AND SPEECH. 

has undergone some damage in early childhood, in consequence of 
which its activity is lowered." 

Feeble-mindedness. — There is a vast difference between the feeble- 
minded individual and the child that appears stupid and dull. The 
feeble-minded may be not mentally up to par, simply from a lack 
of brain development or brain structure, while the dull, listless, 
stupid child may appear so merely because of some pathological con- 
dition or some defect in formation or probably a speech defect, in 
which condition he cannot compete successfully with children of 
his own age and size. He is, therefore, considered dumb and led 
to believe that he is dumb and a wrong mental impression given. 
However, in either of these conditions there is no question that 
first there should be the removal of any mechanical cause in the 
shape of involvement of the structures due to pathological growths, 
and after this, in either case, training will do a great deal toward 
the relief of the defect ; so that in the so-called feeble-minded, by 
a system of constant, persistent, kindly training, the cells, even if 
deficient in number, can be made to do more work, and mentally 
the child can be developed. In the other condition, in which the 
mental hebetude is merely a passing one, dependent on some local 
pathological lesion, the development will be much more rapid and 
results can be more easily obtained after the removal of the cause. 
It must not be forgotten that defective speech may be a mental 
sign of feeble-mindedness. It may also be a physical sign of feeble- 
mindedness. At the same time, the defect of speech is not neces- 
sarily any sign of feeble-mindedness. To be sure, it may be 
associated with it, but you may also have defects of speech asso- 
ciated with diseases of the spinal cord, lesions involving the mus- 
cular apparatus, diseases causing pressure on the nerve supply to 
the larynx, or involving in any way the mechanism of articulation 
and phonation. Hence, the diagnosis in early childhood is of the 
greatest importance. 

The natural mechanism of speech becomes mechanical. Habits 
of speech and faulty mechanism, being mechanical, are yery diffi- 
cult to change, and require special aid and instruction. The 
individual himself may not be so conscious of his defect of speech ; 
in fact, his ear has become accustomed to faulty enunciation and 
articulation. His objective sense of sound perception is faulty, 
and the same is true of his subjective sense of sound perception 
(see relation of voice to hearing, p. 738), 

The ear, after all, is the controller, and it is necessary to train 
the ear so as to regulate the organs of speech. 

Speech is developed during the latter part of the first year and 
on up to three years of life. Any defect of speech, enunciation, or 
articulation developed at this formative period is much more 
difficult to treat than defects which are acquired or developed later. 
The subjective and objective sense of sound perception have be- 



SPEECH DEFECTS. 755 

come accustomed to faulty impressions, and the whole mechanism 
of speech and hearing has to be practically reconstructed. 

The tongue, the teeth, jaws, and lips are equally important in 
phonation, articulation, and enunciation. In fact, the whole upper 
respiratory tract is concerned in sound production. Any defect in 
these parts, whether congenital or acquired, will necessarily in- 
volve in some ways, voice, speech, quality, timbre, articulation, 
enunciation, and resonance. 

Treatment. — In certain sensitive individuals having a slight 
defect of speech, the very fact that they are sensitive interferes 
largely with treatment. Their subjective and objective sense of 
sound perception tells them that they have a defect of speech, and 
they are sensitive to the opinions of others and dread to be criti- 
cized or laughed at. They would rather be considered dumb and not 
make any answer at all than to place themselves in the position to be 
made fun of. This fact is exceedingly important in children, and 
such children should have special teachers and special instruction. 

Our public schools should have teachers for the mentally back- 
ward, the feeble-minded, and the child that shows any tendency 
whatever to mental hebetude and speech defects. 

In any form of mechanical defect of speech the main object in 
treatment is, first of all, to direct mentally the patient's attention 
to some other point, to occupy his mind, and divert his attention 
from the knowledge that he has a defect of speech. This even 
has to be carried to the point of training him to speak incorrectly ; 
in other words, to partially form a habit to break another, but the 
one formed the individual has under control. 

Sir Henry McCormick, in 1828, in his excellent monograph on 
" A Treatise on the Causes and Cure of Hesitation of Speech or 
Stammering," advanced a method which to this day has been most 
beneficial, and the methods today employed are largely based on 
McCormick's method. It is this : The directing of the patient's 
attention to deep inspiration with the abdominal muscles under 
high and tense contraction. Then, each effort of phonation is 
made with the expiratory effort. Each word is made spasmodically, 
or each sound, if necessary, is made individually and spasmodically 
by relaxing the contraction. This method, to be sure, gives a very 
undesirable method of speech, but once the patient has confidence 
in himself that he can speak without stammering, he can gradu- 
ally be trained to forget the new method. I have seen marvelous 
results obtained by this method in a very short time, the patient 
gaining confidence and being able himself to correct his tendency 
to stuttering or stammering. 

The excellent method given by G. Hudson Makuen, of 
Philadelphia, who is really the American authority on the subject 
of " defects of speech," is largely based on this method, which he 



756 VOICE AND SPEECH. 

has improved and developed almost to the point of a new method. 
However, the principle is exactly the same. 

Makuen's Elocutionary Method for the correction of stammer- 
ing is as follows : " The object of this training, of course, is to 
enable the patient to substitute for his faulty method of speaking 
a certain correct method, and, therefore, it is necessary to teach 
him the underlying principles of speech production. He must 
know how to breathe, actively as well as passively. By active 
breathing I mean that which is used for purposes other than the 
support of life. Speaking is one of the things that always requires 
active breathing. The stammerer's breathing may be active, but 
it is always faulty, and the correction of this faulty breathing is 
the first step in the treatment. 

" He must be taught to use the inspiratory muscles and the ex- 
piratory muscles independently, and also to combine their action 
so that he may be able to conserve his breath and at the same time 
use just enough and no more than enough to make and sustain the 
vocal or basic element of speech." 

Breathing and vocal exercises, therefore, should be given, and 
they should be practised for a long time. As Wyllie points out in 
his book on " Disorders of Speech," it is the vocal element that is at 
fault in the majority of stammerers. The voice is not forthcom- 
ing at the instant that it is required for articulation into speech. 
His illustration of the violin is very apt. The bow hand corres- 
ponds to the vocal mechanism and the string fingers to the articu- 
lating mechanism. If the bow hand should cease to move no 
amount of pressing with the string fingers would produce tone. 
When, however, the vocal mechanism wavers or ceases to operate, 
the stammerer tries to make up for the deficiency by forcing the 
articulating mechanism, and there is an overflow of nervous 
energy to the parts, accompanied by the characteristic grimaces and 
contortions, due to the fact that certain muscles of the pharynx, 
mouth, and face are set in motion, but the laryngeal muscles, in- 
trinsic and extrinsic, remain quiescent. His object, of course, 
should be to increase the efficiency and promptitude of the vocal 
mechanism and combine or co-ordinate its action with that of the 
articulating mechanism and brain impulse. 

The articulating mechanism should also receive attention, and 
to this end the elementary sounds of the language should be mas- 
tered. They are forty-four in number and are represented by the 
letters of the alphabet. A little difficulty arises at first from the 
fact that the sounds of the letters in most, instances do not corres- 
pond with their names. The letter " A," for instance, has five 
distinct sounds, as in the words ale, at, alms, all, ask, and the 
sound of the letter " T " is the result of a slight explosion of 
breath between the anterior portion of the hard palate and the tip 
of the tongue, while the sound is represented by the two letters, 



SPEECH DEFECTS. 



757 



" t " and " e." In this way all the elementary sounds of the lan- 
guage should be studied and practised, so that they may be given 
smoothly, easily, and promptly. The elementary sounds have 
been arranged in order by various physicists and formed into a 
table, to which has been given the name "The Physiologic Alpha- 
bet," by Neil Arnott. This was later modified by Dr. John 
Wyllie, of Edinburgh. The alphabet given below is a further 
modification of this, by G. Hudson Makuen, of Philadelphia, and 
is the alphabet used by him in treatment of the various forms of 
defects of speech. Mak lien's Revised Physiological Alphabet con- 
tains forty-four sounds, which are designated as follows : 

The Physiological Alphabet. 



CONSONANTS. 



Voiceless 
Oral. 


Voiced 
Oral. 


Voiced 
Nasal. 


P 

Wh 


B 
W 


M 


F 


v 




TV 


Th" 




S ' 
Sh 


Z 

Zh 




T 


D 

L 
E 




K 


G 


Ng 


H 


Y 





Labials 



Labiodentals 
Linguodentals . 
Anterior . . . 

Linguopalatals 

Posterior . . . 
Linguopalatals 



Paul Brown made white wax. 

Full voice. 
Think vou. 



Some zealous sheep leisurely took 
down nine large rails. 



Can girls bring home yeast ? 



VOWELS. 


COAEESCENTS. 


a 


a le 


6 


6 Id 


ar 


f ar e 


or 


f or e 


a 


a t 


O 


o n 


ar 


far 


or 


for (aw) 


a 
a 

o 

a 


ii 1ms 
a 11 

a sk 


00 

do 

I 


6b ze 
1 dbk 

" it 


er 

er 


here 
h er 


oor 
ur 


p oor 
p ur r 


e 


e ve 


u 


lip 










e 


e Ik 















758 VOICE AND SPEECH. 

Having learned this alphabet, the next step for the stammerer 
is to study its application to words as they occur in speech and 
language. 

An analysis of words will show that they are composed of a 
combination of two or more of the elementary sounds in The 
Physiological Alphabet, and the articulation of words means simply 
the union of two or more of these sounds arranged in their proper 
sequence. Words of more than one syllable should be still 
further divided. A syllable is a combination of elementary 
sounds which may be given with a single respiratory impulse. All 
good speakers syllabicate, or speak in a series of separate respira- 
tory impulses. The stammerer should be taught to emphasize 
this syllabication, or to give to each syllable additional time 
and force. This is for the purpose of acquiring conscious volun- 
tary control over the vocal and respiratory muscles. Moreover, in 
the syllabication of words, as Alexander Graham Bell has pointed 
out, the utterance of each syllable should proceed, as far as possi- 
ble, from the closed to the open position of the organs of articula- 
tion. For illustration, take the word syllabicate. Instead of pro- 
nouncing it syll-ab-ic-ate, the physiological pronunciation of it would 
be sy-lla-bi-cate. 

This is an important point to the stammerer, because it has 
been found to be the normal and physiological method of articula- 
tion and, therefore, the simplest of execution. Considerable prac- 
tice should be given, first, in writing and then in speaking syl- 
labically, and the patient should be encouraged even to think in 
syllables, for it must be borne in mind that in many cases the 
stammerer is addicted to faulty cerebration as well as to faulty 
vocalization and articulation. In other words, the stammerer's 
mind must be occupied by some other thought than speech. In 
the correction of other forms of defects of speech similar methods 
should be followed, with special attention paid to the particular 
defect, whatever it may be. 

The calling of the stammerer's attention to his breathing 
and compelling or requesting him to speak only while in the act 
of exhalation will often be sufficient attraction to divert his mind 
and attention, resulting in the cure of his stammering. 



CHAPTER XXL 

NEUROSES OF THE LARYNX. 

Nervous Cough. Hysterical Aphonia. 

Mogiphonia. Functional Aphonia. 

Anesthesia. Chorea of the Larynx. 

Paresthesia. Dysphonia Spastica. 

Hyperesthesia. Laryngeal Vertigo. 
Neuralgia. 

Paralysis of the Vocal Cords. 

a. Paralysis of the Superior Laryngeal Nerves. 

b. Recurrent Laryngeal Paralysis. 

c. Bilateral Abductor Paralysis. 

d. Unilateral Paralysis of Abductors. 

Paralysis of Individual Muscles. 

a. Paralysis of Central Adductors (Arytenoids). 

6. Paralysis of Internal Tensors (Thy ro- arytenoids). 

c. Bilateral Paralysis of Adductors (Lateral Crico-arytenoids). 

d. Unilateral Adductor Paralysis (Lateral Crico-arytenoid). 

NERVOUS COUGH. 

A spasmodic, croupy, even musical laryngeal cough occurring 
in persons of a neurotic type, for which no other cause can be 
assigned, is to be considered of nervous origin. Continuing through 
the day in distressing spasms or almost continuous, barking in 
character, increased by excitement, when there may be some facial 
twitching, the cough may become a source of annoyance not only 
to the patient himself, but also to those around him. During sleep 
there is usually a remittance of the affection, only to return, on 
waking, with renewed vigor. It is usually seen in hysterical 
females or neurotic males. In the search for possible causes of 
the condition the chest should be carefully examined, the nose and 
nasopharynx should be inspected for abnormality or possible cause 
of reflex irritation, or especially hypersensitive areas whose stimu- 
lation gives rise to the condition. The pharynx and fauces should 
be carefully reviewed for the cough spots of Stoerk or enlarged 
tonsils. The ears should be inspected for impaction of cerumen 
or a foreign body which might reflexly produce the cough. Failing 
by these means to detect the origin of the symptom, attention should 
be given to the digestive and generative tracts. If the search for 
an assignable cause has been unavailing, treat the case as one of 
purely nervous origin. Give nerve-sedatives, such as bromicl of 
soda, 10 grains three times a day, and apply locally every other day 

759 



760 NEUROSES OF THE LARYNX. 

menthol or cocain in benzoinol or liquid albolene, 10 grains to the 
ounce. The affection will be usually found difficult to relieve suc- 
cessfully, and tonics, such as iron, quinin, and arsenic, or a pill 
containing 1 grain each of valerianate of iron and zinc, with cold 
douching, change of air and scene, and outdoor exercise, may 
have to be added before appreciable results can be hoped for. 

MOQIPHONIA. 

Owing to a lack of tension of the vocal cords, singers or speak- 
ers may notice that singing or forced or accentuated speaking may 
become at first difficult and finally impossible. The cords em- 
ployed in ordinary conversation, without the added burden of 
increased effort, as in singing or loud declamation, respond nor- 
mally. The condition is known as mogiphonia, and is analogous to 
other occupation-neuroses, such as writer's cramp, etc. The affec- 
tion may simulate either the tremulous or paralytic variety of this 
disease, the latter form, according to Frankel, being the more 
important. Massage and friction give best results in the treat- 
ment. 

ANESTHESIA. 

Etiology. — Loss of sensation of the larynx may be artificially 
produced by the use of a general or local anesthetic. In hysteria, 
during epileptic seizures, in the later stages of cholera, in paral- 
ysis of the insane, and in bulbar paralysis anesthesia of the larynx 
may occur. If occurring after diphtheria both sides of the larynx 
are insensitive, and are usually bereft of motion as well. As a rule, 
motor paresis of the larynx and palate have an associated loss of 
sensation. Such intracranial lesions as softening, hemorrhage, 
tumors, cysts, and gummata usually produce unilateral anesthesia, 
if affecting one side of the medulla. Locomotor ataxia, progressive 
muscular atrophy, and railway spine may also produce an absence 
of sensation in the larynx as one of the symptoms of their involve- 
ment. Erysipelatous or variolous affections of the larynx may 
leave the condition as a sequel. Loss of function of the superior 
laryngeal nerve or certain fibers of the pneumogastric by any of the 
causes mentioned above explains the mechanism of the condition. 

Symptoms. — The tendency for food or drink to enter the 
trachea and set up spasms of choking or coughing is the most 
prominent symptom of the affection. A septic pneumonia from 
the lodgement of foreign matter in the lung should always be 
feared. Inspection with the laryngeal mirror may show an erect 
epiglottis due to the paresis of the thyro- and ary-epiglottic mus- 
cles. Morell Mackenzie has spoken of a waviness in the outline 
of the glottis due to the same cause. 

The diagnosis can be substantiated by the failure of response 



PARESTHESIA. 761 

when the larynx is touched with the probe, neither sensation of 
any kind, nor cough, nor reflex closure of the glottis occurring 
after such a procedure. 

Prognosis. — The prognosis for this condition depends on the 
cause. Diphtheria's relation to the condition generally gives a 
better outlook for cure than any of the others, despite the most 
energetic treatment. 

Treatment. — Food should be given through the stomach- 
tube to prevent its entrance into the respiratory tract. Care 
should be taken to pass the tube well back in the pharynx, so as to 
be sure to enter the esophagus, as the anesthetic condition of the 
larynx gives no sign of its accidental insertion into that structure. 
Strychnin hypodermically, or by the mouth in large doses, to its 
physiological limit, with electricity three to six times a week to 
the point of producing sensation but not pain, and massage are 
the mainstays of a treatment that is at best tentative in the 
majority of cases. 

PARESTHESIA. 

Under the heading of paresthesia of the larynx are grouped 
those perversions of sensation referred to that structure, compris- 
ing prickling, heat, tickling, the feeling as of a foreign body, and 
constriction. If the sensation be one suggestive of the presence 
of a foreign body, it can be explained by one of three solutions : 
Either that a foreign substance before removal had given rise to 
change in the structure about the peripheral nerve-filaments of 
such a character as to leave a continuation of impulses simulating 
those transmitted during its actual presence. Again, pathological 
changes in the throat, such as enlargement of the faucial tonsil, 
cheesy concretions in the crypts of the tonsil, elongated uvula, 
follicular pharyngitis, enlarged veins at the base of the tongue, 
enlargement of the lingual, pharyngeal, or laryngeal tonsil, neo- 
plasms, or foreign body, may give rise to the same set of impulses. 
Or, lastly, some affection more or less remote may reflexly act in 
the same manner. It is presupposed that careful search for a 
foreign body in the larynx or its adnexa has eliminated such a 
possibility. In anemia, hypochondriasis, hysteria, and phthisis 
careful search of the throat and lungs should be made for abnor- 
mality or actual disease before a purely nervous origin is attributed 
to the condition. Especially if the laryngeal mucosa be anemic 
should the lungs be carefully examined for the possibility of an 
incipient phthisical involvement. 

The patient may become so fearful of cancerous or other 
malignant involvement, because of the pain, especially if increased 
on breathing or swallowing, that the refraining from these func- 
tions or partial control of them to obviate the pain may endanger 
his life. In such cases strong moral suasion should be brought to 



762 NEUROSES OF THE LARYNX. 

bear as part of the treatment, and hypnotism may be employed in 
some cases to advantage. When actual pathological change exists 
elsewhere, it should be remedied. The general health should be 
built up by tonics, outdoor exercise, and diet. Bromid of soda 
may be given internally or as an inhalation. Menthol, 10 grains 
to the ounce of albolene, may be applied locally with advantage. 

HYPERESTHESIA. 

The sensitiveness of the laryngeal mucosa varies largely in 
different individuals in apparently good health, and in those of 
nervous temperament this reflex sensibility may be so great as to 
be termed hyperesthetic. Acute and chronic laryngitis renders 
the larynx acutely non-tolerant of foreign interference. Ulcera- 
tion, excoriation, small tumors, especially carcinomata, fissures at 
the base of the tongue or on the pharyngeal walls, tonsils, or pala- 
tine folds, incipient phthisis, bibulous pharyngitis, hysteria, the 
gouty or rheumatic diathesis, may all contribute in a greater or 
less degree to hypersensitiveness of the larynx. Cough that is 
peculiarly irritating, gagging, spasm, and even convulsive seizures 
may be produced by the slightest irritation, either by examination, 
the inhalation of cold air, dust, or smoke, or by contact of certain 
substances in deglutition. 

The treatment should consist in the careful search for, and 
removal of, the cause of the condition. Abnormalities in surround- 
ing structures should be corrected. Ulcerations, excoriations, and 
fissures should be carefully cleansed, and touched with a solution 
of nitrate of silver, 40 grains to the ounce, or even the solid stick, 
milder solutions being employed if stimulation is desired. The 
gouty or rheumatic involvement should be combated by the 
administration of colchicum, the iodids, or salicylates. If of 
nervous origin sedatives, such as bromid of soda, chloral, the 
triple bromids, and tonics, may be given. The application of 
sedatives locally should consist in the careful employment of 
cocain or menthol in spray form, in the strength of 5 to 10 grains 
to the ounce of benzoinol. Ice-water spray may be employed to 
advantage in some cases in obtunding the hyperesthesia of the 
tissues. The eliminative functions should be looked to and cor- 
rected regardless of the etiological factor. Change of air, sea- 
bathing, and outdoor exercise should be insisted upon when 
practicable. 

NEURALGIA. 

Pain in the larynx, that can undoubtedly be said to be purely 
nervous in origin, is rarely met with. Usually some lesion, either 
in the larynx itself or in some adjacent structure, will be found 
responsible for the condition. Phthisis, rheumatism, gout, anemia, 



HYSTERICAL APHONIA. 763 

and malignant disease may give rise to pain in the larynx, and 
should be eliminated as causative factors before an absolute diag- 
nosis is made. The majority of the causes that have been enu- 
merated as bearing etiological relation to hyperesthesia of the 
larynx may, by intensification, produce actual pain in that organ. 
The treatment should be addressed to the elimination or cure 
of the underlying cause. For purely neuralgic pain phenacetin, 
acetanilid, or any of the coal-tar analgesics, cannabis indica, acon- 
itin — gr. y^- — until physiological effect is produced, or in some 
cases morphin may be administered. Menthol or cocain locally, 
hot Avater externally, or a small mustard plaster applied in the 
same manner may be effective in relieving the pain. 

HYSTERICAL APHONIA. 

The hysterical individual desires and deserves much sympathy 
and consideration. There is a vast difference between the indi- 
vidual who simulates symptoms and disease, the malingerer, and 
the true hysterical person, — one is wilful and the other is lack of 
will-power. I have seen a number of cases of hysterical aphonia 
both in private and hospital patients, and will cite a few cases 
illustrating that this condition is seen at varying ages, under 
curious circumstances, in nervous individuals and in seemingly 
healthy persons. 

Hysterical aphonia is sudden, complete loss of voice, without a 
discoverable pathological lesion for its causation. It seems to 
consist in a temporary loss of control of the adductor nervous 
mechanism by the cerebral centers. Shocks, frights, anger, inten- 
sification, for any reason, of any emotional attitudes in a neurotic 
individual often immediately precede the condition ; or the patient 
may retire in full possession of the voice and awake to find any 
attempt at vocalization impossible. The voice may be entirely 
lost ; in others a whispering note may be the only attainable result 
of attempt at phonation. (In the majority of cases I have observed 
almost entirely lip motion without sound.) This condition may 
persist for a time and full return of the vocal powers occur as sud- 
denly and mysteriously as their disappearance, only to be lost again 
at periods varying with each individual case. 

The diagnosis of the affection rests on the general nervous 
aspect of the case and laryngeal image, which reveals an appar- 
ently healthy condition of the laryngeal mucosa, an absence of in- 
trinsic growth, and perfect ordering of the nervous laryngeal 
mechanism, except that on attempted phonation both vocal cords 
are seen to begin to approach the median line, but fail at a point 
short of approximation. Having for a moment been almost ap- 
proximated, the controlling power being lost, they immediately 
resume the partially approximated position. The character of 



764 ' NEUROSES OF THE LARYNX. 

cough in hysterical aphonia is entirely different from that in 
true adductor paralysis. As in hysterical manifestations of any 
genuine paralysis elsewhere, the laryngeal findings never form 
an accurate replica of any genuine paralysis. The important 
point, and the one to be emphasized in hysterical aphonia, is 
that while it is one that can always be assumed under voluntary 
effort, it is still one which is assumed by the patient under the 
influence of a strange psychical condition, or by whatever other 
term we may choose to designate it, and note one which the patient 
wilfully assumes with the desire to deceive or excite sympathy. 

Furthermore, hysterical aphonia or paralysis counterfeits only 
those forms of paralysis which can be assumed by voluntary 
effort. Adduction of the cords being purely an involuntary 
motion and occurring only during the act of inspiration, paralysis 
of the abductors is not met with as a functional or hysterical 
paralysis. A unilateral paralysis of the vocal cords can never 
occur as a hysterical or functional affection. The condition seems 
that of imperfect approximation of the cords, with chorea or trem- 
bling, resembling that which we meet with in double paralysis of 
the recurrent laryngeal nerve. The patient does, however, adduct 
the cords to a slight degree, and the sound produced by the passage 
of air through the partially closed rima glottidis is transformed into 
articulate speech by the lips and tongue, etc. The voice is lost 
and the patient simply communicates in a whisper. 

Laryngeal examination will reveal the normal mobility of the 
cords. Those cases of aphonia due to mechanical interference 
with the proper closure of the cords on account of thickening of 
the mucous membrane covering the arytenoids or the commis- 
sure may also be simulated, but will easily be recognized. The 
hysterical affection may resemble double paralysis of the recurrent 
laryngeal nerves ; in this, however, all the muscles of the larynx 
are completely paralyzed, the cords are absolutely motionless, 
and in a position midway between extreme adduction and abduc- 
tion. Besides, double paralysis is very rare, and while the cords 
are motionless, they do not occupy the same relative position. 
This position of the vocal cords cannot be assumed or simulated, 
for the instant that inspiration occurs the glottis will be widened 
and movement can be seen to take place. Hysterical paralysis is 
always bilateral and always assumes the form of incomplete 
closure of the glottis. 

A careful study of the larynx will clear up the diagnosis of 
these cases and enable one to determine that the aphonia is a func- 
tional disorder, and not due to any pathological lesion, simply by 
exclusion ; for, as a rule, the laryngeal image does not and will 
not present a complete picture of any of the forms of genuine 
paralysis. There will also be accompanying evidences of the hys- 
terical temperament. Usually cough is present in hysterical 



HYSTERICAL APHONIA. 765 

aphonia, while in genuine paralysis of the adductors it is en- 
tirely lost, the possibility of a cough being dependent on the 
ability to close the glottis. Furthermore, this form of laryngeal 
paralysis comes on without any previous warning whatever. 

Hysterical aphonia has been observed in combination with 
spastic dyspnea. Very frequently a diminution or loss of sensi- 
bility in the mucous membrane of the larynx and pharynx exists, 
with loss of movement in the former. 

I think in many cases, in fact all, if we could get the complete 
history we would find some underlying cause, such as anger, 
fright, shock, stubbornness, grief, or worry. 

There have been many methods suggested for the restora- 
tion of the voice in these hysterical cases. Even such radical 
measures as the giving of an anesthetic mav have to be resorted 
to. This is also an excellent means of diagnosis, as it will 
only restore the voice in hysterical cases, but not in any true 
lesion of the vocal cord. 

Treatment. — Personally, I have had such excellent results by 
the use of the falsetto voice that I use this method entirely. The 
employment of this method is as follows : 

I have the patient use the falsetto or head tones, having the 
mouth tightly closed, and the patient striking a high note, resound- 
ing in the vault of the nasopharynx. After keeping this up for 
some little time, lowering the pitch, and with each attempt the 
patient getting more confidence in the head-tone, and gradually 
lowering the tone and increasing the volume, tell the patient, 
when making the head-tone, to open the mouth. After repeating 
this several times and lowering the pitch each time as the 
patient opens the mouth, have them continue in the same tone, 
repeating a word after you, and he will suddenly realize that he is 
talking. I have never known this method to fail in a true case of 
hysterical aphonia. The attention of the patient is directed to the 
nose rather than to the larynx and he does not realize that 
the sound is really being produced in the latter organ. 

The treatment of the case should never rest on the hypothe- 
sis that the loss of voice is under the control of the patient and 
can be voluntarily recalled. Any possible exciting factor, such 
as disease of the generative tract, should be remedied. Any co- 
existing abnormality of the adjacent respiratory tract should be 
corrected. Malarial influence, if suspected, should receive its 
proper treatment. The general health should be looked after and 
tonics or blood-making drugs administered. Gain the confidence 
of the patient and suggest the return of function after a certain 
period of medication, general or local. Hypnotism has been em- 
ployed with brilliant results. Mental shock, such as might be 
produced by preparation for surgical interference, may effect 
return of the voice. Electricity has been used to advantage. 



766 NEUROSES OF THE LARYNX. 

Strychnin pushed to its physiological limit, valerianate of ammonia 
in dram doses night and morning, arsenic, and kola have given 
relief in certain cases. 



FUNCTIONAL APHONIA. 

Functional aphonia is a condition dependent upon systemic 
lesions and always associated with anemia or any condition in 
which the individual is below par. It is due to a weakness of the 
adductor muscles, and is never caused primarily by organic lesion 
of the nerve-centers or trunks. When the adductor muscles are 
primarily affected there is usually only a functional lesion, while if 
the abductor muscles are primarily affected there is, in a vast major- 
ity of cases, organic lesion. There are practically no symptoms 
associated with functional aphonia, the larynx presenting nothing 
abnormal except a pale, anemic membrane. On attempted phona- 
tion on the part of the individual the adductor muscles fail to 
meet ; hence the loss of voice, the patient usually speaking in a 
peculiar, hollow whisper. 

Functional aphonia in itself is not serious, but the condition of 
the patient which predisposes the functional aphonia would also 
predispose that individual to infections on account of his lowered 
cell resistance, so that this condition might be observed in early 
stages or as a precursor of laryngeal tuberculosis. 

The treatment of this condition is self-evident. 

CHOREA OF THE LARYNX. 

Synonym. — Laryngeal nystagmus. 

The monotonous occurrence, at intervals during the day as 
short as a few minutes, of a sharp, dry, noisy cough resembling a 
bark or yelp, dependent upon the violent involuntary incoordinate 
spasm of the vocal cords, is known as chorea laryngis, or chorea 
of the larynx. It occurs usually in females about the age of 
puberty. The noise produced is not like a true cough, as there is 
no precedent drawing in of the breath, but consists in a single 
sudden expiratory bark, or a series of similar noises diminishing 
in intensity. There may or may not be choreic movements in 
other parts of the body. The tone of the voice is not affected, 
though there may be occasionally a jerkiness in articulation. The 
laryngeal image between the attacks is to all appearances normal. 
When the seizure begins, the cords are seen to suddenly clap 
together as if driven by force ; remaining in this position momen- 
tarily, they as rapidly fly back close to the sides of the larynx. 
This spasm excites expulsive effort on the part of the thoracic 
muscles, and the glottis is forced open with the resultant charac- 
teristic sound. 



LARYNGEAL VERTLGO. 767 

The treatment depends upon the removal of any morbid 
condition in the air-tract and the inhalation of sedatives, such as 
tincture benzoin compound, paregoric, infusion of hyoscyamus, hot 
steam, or the application of cocain or morphin locally. The bro- 
mids pushed to tolerance may do good, but the condition is essen- 
tially chronic and intractable. General and nerve tonics, omitting 
strychnin, should be ordered, and the skin and system toned up 
by cold douches, plunges, or showers. The faradic and galvanic 
currents have both been advised as giving beneficial results. 

DYSPHONIA SPASTICA. 

Synonym. — Spastic paraplegia of the larynx. 

Spasm of the glottis only on attempted phonation is called 
dysphonia spastica. The affection occurs in adult life, and more 
often in females than in males. Impairment or loss of voice pre- 
cedes the peculiar spasmodic attacks, in which, when phonation is 
attempted, the glottis is drawn tightly shut, remaining closed as 
long as the patient continues his efforts to use his voice, and ceases 
when there is no further attempt made at conversation. Overuse 
of the voice seems in some cases to precipitate the attack, which, 
if efforts at use of the voice be persisted in, may cause a certain 
amount of cyanosis. 

The laryngeal image, when attempts to speak are made, is nor- 
mal until the cords are approximated, in which condition they per- 
sist in tonic spasm so severe that one cord may overlap the other. 
The movements of the laryngeal muscles during respiration differ 
in no way from health. 

The affection is chronic and the treatment may occasionally 
have little effect on its course. Any abnormality or disease of the 
respiratory tract or elsewhere that may reflexly or otherwise cause 
the condition should be remedied. Healthful exercise, proper 
clothing, the cold sponge or shower, and a nutritious diet should 
be prescribed. Such general tonics as iron, quinin, cod-liver 
oil, or the hypophosphites may be ordered. Rest of the voice 
should be insisted upon, and the constant current applied every 
other day until effect is produced. The bromids internally, and 
such antispasmodic or anesthetic local applications by inhalation 
or spray as infusion of poppies, cocain, menthol, or infusion of 
hyoscyamus, may be used to advantage. 

LARYNGEAL VERTIGO. 

Synonym. — Spasmodic laryngeal occlusion. 

"Without premonition, except a slight cough set up by a feeling 
of tickling in the larynx, a person apparently enjoying good health 
may be suddenly seized with giddiness, blurring of vision, and 



768 NEUROSES OF THE LARYNX. 

unconsciousness, caused by spasm of the larynx. Remaining in 
that condition but a few seconds, during which time there may be 
spasmodic twitching of the face or limbs, he recovers at once from 
the attack, experiencing no disagreeable consequences except, per- 
haps, a fleeting sensation of confusion. This affection, known as 
laryngeal vertigo, is rare. A chronic or acute inflammation of the 
larynx, coupled with overexertion, fatigue, or nervous excitement, 
has been recorded as precipitating an attack. The seizures do not 
take place at regular intervals, but may be weeks or months apart, 
and, as a rule, occur without an assignable cause. Just as the 
attack comes on there is a deep sucking in of the air, which, 
imprisoned by the glottic spasm, increases the pressure in the 
chest, lessens the heart-action, produces syncope, and eventually 
lowers the health and undermines nervous equipoise. 

The prognosis for this startling, and often alarming, affection 
is happily good under proper treatment, which should consist in 
promptly putting the individual under the full influence of the 
bromids and correcting any diseased condition found existing in 
the upper respiratory tract. Measures like those employed under 
Dysphonia Spastica (page 767) are also to be used in this disease. 

PARALYSIS OF THE VOCAL CORDS. 

Paralysis of the Superior laryngeal Nerves. — By the 
superior laryngeal nerves the mucous membrane of the larynx is 
supplied with sensation, and by the same means motion is imparted 
to the cricothyroid muscles and, in part, to the arytenoideus. 

Paralysis, then, of this nerve would cause a loss of sensation 
in the lining of the larynx and an interference with or loss of 
voice, as the muscles which render the cords tense are at fault. 
Either one or both sides of the larynx may be involved. 

The condition may be caused by diphtheria, overuse of an 
inflamed larynx in singing or shouting, by exposing the neck and 
catching cold, or by injury or section of the nerve. The paralysis 
is rarely complete, except when due to the last group of causes. 

The main symptoms of the paretic involvement are a hoarse- 
ness of the voice, an inability to produce the higher notes, or a 
peculiar " sliding rise in the pitch of the voice during ordinary 
conversation, which is beyond control of the patient." 

Diagnosis. — In a well-marked case of bilateral paralysis of 
the superior laryngeal nerve, the image in the mirror is at once 
curious and characteristic (Fig. 250, 1). The approximation of the 
vocal processes divides the glottic aperture into two unequal parts 
— " a wavy outline," as Sir Morell Mackenzie expressed it. The 
lack of tension of the cricothyroid muscle, together with anesthe- 
sia of the larynx, makes certain the diagnosis. In unilateral 
paralysis there is a relaxation of that part of the affected cord be- 
tween the vocal process and the thyroid cartilage. 



PABALYSIS OF THE VOCAL COEDS. 



769 



Prognosis. — The outlook for recovery in the majority of 
cases is good, the duration of the condition depending on the cause. 
Post-diphtheritic involvement usually lasts from one to three 
months, while recovery of the voice may be delayed for a year if 
the loss was due to section of the nerve. 

Treatment. — Mild cases will usually recover in time if left 
to themselves, but judicious treatment, such as mild counterirrita- 
tion by iodin, or a mustard plaster, or wet compresses, will hasten 
the desired end. In the severer cases food may have to be given 
through the stomach-tube, on account of the danger of its entrance 




Fig. 250.— 1, Bilateral paralysis of superior laryngeal nerve ; 2, cadaveric position of 
cords seen in bilateral paralysis of recurrent laryngeal nerve : 3, unilateral paralysis 
of right abductor during deep inspiration ; 4, paralysis of the arytenoideus muscle"; 5, 
bilateral adductor paralysis : 6, bilateral paralysis of abductors (crico-arytenoidei pos- 
tici) : this is the image during deep inspiratory effort. 






into the trachea owing to the anesthetic larynx. Strychnin in full 
dosage, friction, massage, and the galvanic or faradic current 
should be employed to promote return of sensation and motion. 
The electrode shown in Fig. 251 is one of the best for electric 
applications. In all cases the voice should be given as much rest 
as possible. Any inflammatory condition of the upper air-tract 
should receive prompt attention along the lines laid down in the 
special chapters. 

Recurrent laryngeal Paralysis. — The movements of all 
of the muscles of the larynx except the cricothyroid and aryte- 

49 



770 NEUROSES OF THE LARYNX. 



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PARALYSIS OF THE VOCAL CORDS. 771 

noideus are controlled by the recurrent laryngeal nerve, so that by 
its paralysis the motion of the affected side is entirely lost, the 
immuned cricothyroid causing no appreciable motion. 




Fig. 251.— Mackenzie's improved laryngeal electrode for paralysis of the cords. 

Etiology. — Pressure on the nerve during its course is the most 
frequently observed cause of paralysis. Particularly is this true 
of the left side, where, by its close anatomical relation to the arch 
of the aorta, its power of transmission is exceedingly likely to be 
interfered with, especially by aneurysmal dilatation of that vessel. 
Enlarged lymphatic glands, mediastinal growths, cancer of the 
esophagus, pleuritic adhesions in incipient phthisis (more likely 
on the right side than on the left, because the pleura extends up 
higher on the right), effusion into the pleural and pericardial sacs 
may also, by pressure on the nerve during its course, cause 
paralysis. 

Central lesion, either by hemorrhage, embolism, endocarditis, 
disseminated sclerosis, or the ascending sclerosis of locomotor 
ataxia, may produce a similar result. 

The toxemia of such diseases as diphtheria and typhoid fever 
causes paralysis by giving rise to a toxic neuritis. The effect of 
these diseases on the terminal filaments of the nerves, either by 
the inflammatory involvement or by the local effect of the toxins, 
is to be considered. Local inflammation in the larynx, as of a 
simple laryngitis, may also bear an etiological relation to the 
condition. 

Symptoms. — Weakening of the voice rather than hoarseness 
is noted if there be unilateral involvement. Complete aphonia is 
the rule if both recurrent nerves be affected, the patient being 
able to speak only in a labored whisper. 

In paralysis of only one nerve the voice after a time gains 
strength by the healthy cord being brought over against its affected 
fellow by the muscles of the sound side. 

Other symptoms, such as cough, dyspnea, etc., are accidental 
and not relevant. 

Diagnosis. — In bilateral paralysis of the recurrent nerve the 
laryngeal mirror shows (Fig. 250, 2) the cords lying relaxed 
midway between adduction and pronounced abduction — the cada- 
veric position. The affected cord in one-sided involvement 



i 



772 NEUROSES OF THE LARYNX. 

assumes a similar position, while the healthy side swings past its 
normal position in its attempt to meet its fellow, the sound aryte- 
noid cartilage passing somewhat in front and beyond that of the 
affected side. In determining this obliquity of the chink of the 
glottis with accuracy, align the center of the arytenoid commissure 
with the center of the epiglottis, or if that be at an angle, with 
the center of the soft palate and uvula, and observe the failure of 
the affected cord to approach the center. 

Having established the condition, search the nervous system, 
the cervical region, and the chest for the underlying cause. 

Prognosis. — The prognosis of the condition depends entirely 
on the underlying cause. If due to diphtheria or allied affections, 
recovery may be looked for in from four to eight weeks. If, how- 
ever, graver chronic disease or abnormality be the faulty factor, 
on their duration and possibility of cure the outlook entirely de- 
pends. Disease of the muscles for eight to ten months will produce 
atrophic changes in them, so that even should the conductive power 
of the nerve be restored, the muscles will be found irresponsive. 

Treatment. — The treatment depends solely upon the underly- 
ing cause. If due to local inflammation, its appropriate treatment 
will be found elsewhere. Dependent upon diphtheria or allied 
conditions, strychnin in full doses, tonics, and electricity should be 
employed, placing one pole on the nape of the neck and the other 
on the larynx externally or within the cavity of that structure, 
which latter procedure is rendered possible by the use of cocain. 
Aneurysm or incurable diseases as a cause interdict the use of 
electricity as not only useless but absolutely harmful. Should, 
however, there exist a reasonable possibility of removing such an 
offending cause as tumor, pleural effusion, etc., the tone of the 
muscles should be kept normal by the use of the galvanic or 
faradic current twice a week. 

Bilateral Abductor Paralysis. — Opening of the glottis 
during inspiration, to permit the entrance of air into the lungs, 
is effected by the action of the posterior crico-arytenoid muscles 
separating the vocal cords, and is presided over by a distinct 
nerve-center in the medulla. 

Etiology. — The usual cause of bilateral abductor paralysis is a 
lesion, such as syphilis of the central nervous system, implicating 
the centers controlling the separation of the cords. Degenerative 
changes of these central areas maybe produced by numerous other 
systemic or local affections — for instance, locomotor ataxia or 
neoplasms. 

Bilateral involvement of the recurrent nerve during its course 
by tumor of the mediastinum, goiter, aneurysm, and cancer of the 
esophagus or thyroid gland are causes of rarer occurrence than 
those just mentioned. 

Again, peripheral causes, such as inflammation of the larynx 



PARALYSIS OF THE VOCAL COEDS. 773 

due to the " exposed location and ceaseless activity of these mus- 
cles/' more rarely bring about a similar result. Hysteria also 
should be borne in mind as a possible etiological factor. There 
is a condition, however, which simulates paralysis of one or both 
cords, in which the patient is unable to speak or, at least, fairly in- 
telligibly pronunciate. I have seen two such cases in which the 
only symptom of paralysis was this failure of voice. There was 
a certain lack of motion of the cords, with no apparent struc- 
tural change. I believe that the condition was due to a super- 
ficial anesthesia of the mucous membrane, and that the patient 
was unable to produce the sound, not from a lack of motion of the 
structure so much as from the sensation of vibration. The cases 
observed made uninterrupted recovery, w T ith no special local treat- 
ment, and there was no other evidence of paralysis or central 
lesion. 

Symptoms. — Difficulty in the entrance of air through the 
laryngeal opening comes on slowly and gradually. At first some- 
what mild, the attack of " inspiratory dyspnea " becomes progres- 
sively worse and more frequent in occurrence. A noisy stridor 
during inspiration develops, and efforts to force the air through 
the glottis, narrowed by the approximation of the cords, becomes 
labored and distressing. On the slightest exertion or excitement 
great shortness of breath supervenes. Expiration is unaffectedly 
quiet throughout. The voice is not affected, except, perhaps, 
slightly weakened. Cough and expectoration are difficult. 

Diagnosis. — Except ankylosis of the crico-arytenoid joints, oc- 
curring for the most part in cancer of the esophagus or tubercular 
laryngitis, there is no image in the laryngeal mirror apt to be mis- 
taken for this bilateral paralysis of the abductor. During inspira- 
tion the cords are seen (Fig. 250, 6) lying motionless near the 
median line instead of being widely drawn apart by the abductor 
muscles. Expiration forces the cords apart and effects exit for 
the column of outgoing air. The phonatory image is not affected, 
the cords responding sharply and normally to efforts at speech. 
In aneurism the paralysis is early and in tumors it is late. 

Prognosis. — The prognosis depends wholly on the underlying 
etiological factor. Rapid development of the disease generally 
augurs a better and speedier outcome than a slowly oncoming 
affection. The possibility of a fatal attack of dyspnea should be 
borne in mind in giving a prognosis ; also that, after paralysis 
lasting nine months to a year, return of motion to the affected 
muscles is practically impossible. 

Treatment. — If the paralysis is due to peripheral irritation, 
the condition should be treated by astringent and stimulating 
vapors or sprays. Should syphilis play the role of etiological fac- 
tor, potassium iodid should be pushed to tolerance, keeping up a 
course of electricity to preserve muscle tonus until the remedial 
agent has had effect. When incurable lesion causes the condition, 



774 NEUROSES OF THE LARYNX. 

the employment of electricity is entirely unnecessary, and in cer- 
tain cases hurtful. Should cure be within the range of possibility, 
massage, friction, strychnin, and the electric current should be 
assiduously employed. 

The danger of sudden asphyxiation should keep the surgeon 
constantly prepared to do an intubation or, better, a tracheotomy. 
For progressively worse attacks of dyspnea in which the diagnosis 
is clearly substantiated, tracheotomy is clearly indicated, not only 
to save life, but by removing the distressing and deleterious effects 
of the dyspneic paroxysms to give wider scope for medication. 

Krause has suggested section of both recurrent laryngeal nerves, 
which, according to Bosworth, would throw both cords into the 
cadaveric position, and while relieving the dyspneic attacks, would 
cause a loss of voice. 

Unilateral Paralysis of the Abductors. — The paralysis 
of one of the muscles of abduction of the vocal cords (cricothy- 
roid) may be due (1) to central lesion, (2) to pressure on the nerve 
during its course by intrathoracic aneurysm or malignant disease, 
or a thickened pleura, (3) to acute inflammation or other intra- 
laryngeal processes involving the nerve peripherally, or (4) to 
gout, rheumatism, plumbism, diphtheria, enteric fever, and other 
acute infectious diseases. 

The symptoms, usually very mild — consisting only in short- 
ness of breath on exertion, probably due to the disease underlying 
the paralysis — are not paroxysmal in character. The voice is not 
affected. The laryngeal mirror during phonation shows no ab- 
normality ; but during inspiration the cord of the affected side lies 
motionless in the center-line, while the sound cord is drawn away 
normally (Fig. 250, 3). 

The prognosis depends on the cause, and the possibility that 
implication of both sides may occur before the disease or condition 
producing the paralysis has run its course should always render 
the prognosis proportionately guarded. 

The treatment should be addressed to the factor causing the 
paralysis along the lines laid down under Bilateral Paralysis of 
the Abductors. Tracheotomy is never indicated. 

PARALYSIS OF INDIVIDUAL MUSCLES. 

Under this heading will be considered all those paralytic lesions 
of the other laryngeal muscles that are due to myopathic causes. 
With but few exceptions they are rare, usually the resultants of 
local inflammation ; or when associated with systemic diseases like 
rheumatism, lead-poisoning, gout, etc., are produced by the super- 
imposition of overuse of the voice or exposure on the local laryn- 
geal exhibition of the general condition. 

Paralysis of the Central Adductors (Arytenoids).— The 
arytenoid muscles alone may be affected by paralysis, or the crico- 



PARALYSIS OF INDIVIDUAL MUSCLES. 775 

thyroids also may be involved, if there is paralysis of the superior 
laryngeal nerve. The causes of paralysis of the central adductors 
are chronic inflammatory conditions of the larynx, hysteria, incipi- 
ent phthisis, diphtheria, or prolonged and severe illness of any 
kind. Hoarseness and a voice that easily tires or becomes lost are 
the symptoms produced by the partial closure of the glottis. The 
laryngeal image is characteristic, and consists, on attempted pho- 
nation, of accurate approximation of the cords for their anterior 
two-thirds, while a triangular opening is left from this point with 
the vocal processes at the apex, due to the failure of the arytenoids 
to contract (Fig. 250, 4). 

Paralysis of the Internal Tensors (Thyro-arytenoids). 
— This is the commonest form of paralysis of the cords, because by 
their anatomical relation, lying just beneath the mucous membrane 
covering the under surface of the cords, the thyro-arytenoid mus- 
cles are most often implicated in inflammatory processes involving 
this region. It may be bilateral or confined to one side of the 
larynx. Overuse of an inflamed larynx in singing or speaking, 
fatigue or strain of the muscles, and hysteria or diphtheria are the 
commonest causes of the condition. The voice is altered by being 
weakened and limited in range, the higher notes being either 
entirely lost or reached after painful effort. In severe cases the 
voice is reduced to a labored whisper. 

The appearance of the cords during phonation renders the 
diagnosis easy, for instead of closely approximating, there is seen 
an elliptical opening extending the whole length of the glottis, 
produced by the cords bellying up before the current of air instead 
of being tightly tensed, as they normally would be by sound thyro- 
arytenoids. 

Bilateral Paralysis of Adductors (lateral Crico- Ary- 
tenoids). — Hysterical aphonia is usually treated under this head- 
ing, but that condition being rather a paresis than paralysis of the 
cords, is considered elsewhere under Hysterical Aphonia. Bos worth 
asserts that, while he has never seen an instance of this disease, a 
genuine myopathic paralysis involving the lateral crico-arytenoid 
muscles may be due to lead-poisoning, exposure to cold, to diph- 
theria, or to any of the exanthemata, and would give rise to com- 
plete loss of voice with phonatory waste. The laryngeal image 
(Fig. 250, 5) so closely resembles that of double recurrent nerve 
paralysis that differentiation is practically impossible. 

Unilateral Adductor Paralysis (lateral Crico -Aryte- 
noid). — This condition is not only extremely rare, but also pecul- 
iarly difficult to diagnosticate. Myopathic paralysis, due to the 
same causes as mentioned above, has occasioned the condition 
which is characterized by impairment or absence of phonation. 
During phonation the affected cord lies tightly drawn in complete 
abduction, while its fellow tries by extra effort, passing over the 



776 NEUROSES OF THE LARYNX. 

central line, to effect approximation, the sound arytenoid cartilage 
passing in front of that of the affected side. 

Prognosis. — The prognosis for all the preceding conditions 
depends on the character of the underlying cause and the length 
of time it has been operative. If consequent upon one of the 
acute infectious diseases or exposure, the outlook for spontaneous 
or speedy recovery under proper treatment is good. The inability 
to procure absolute rest for the affected muscles makes the prog- 
ress proportionately graver, especially in involvement of the thyro- 
arytenoids. 

Treatment. — Removal of the cause should be the first reme- 
dial effort. Rest that is as nearly complete as possible should be 
insisted upon by forbidding loud or prolonged use of the voice, 
limiting necessary conversation to an easily produced whisper. 

Faradism or, failing this, galvanism should be applied daily to 
the affected muscles for five to ten minutes. Use both electrodes 
within the larynx, or place one on the outside of that organ, while 
the other is introduced through the mouth. 

Strychnin pushed to full tolerance is an admirable adjuvant. 
The general health should receive proper hygienic and tonic treat- 
ment by the ordering of cold sponges, followed by friction, massage, 
outdoor exercise, and liberal diet, together with coca wine, kola, 
and the other vegetable and mineral tonics. 



CHAPTEE XXII. 
INTUBATION OF THE LARYNX. 

Definition. — Intubation, or, as it is termed from the name of 
the physician to whom we owe the perfected operation, O'Dwyer's 
operation, consists in the location within the larynx of a suitable 
respiratory tube for the relief of dyspnea due to certain forms of 
laryngeal obstruction. 

Indications. — The indications for this procedure may all be 




Fig. 232— Showing intubation tube just entering the larynx, as well as the method of 

introduction. 

referred to a single condition — namely, an obstructive dyspnea 
threatening life and arising from an occluded condition of the 

777 



778 INTUBATION OF THE LARYNX. 

larynx, other than a glottic spasm. The difference between the 
indications for tracheotomy and for intubation is one largely of 
degree rather than kind. The operation naturally finds its great- 
est utility in the treatment of membranous occlusions, either local- 
ized within the larynx or extending into it from above. The 
dangers of edematous conditions caused by inhalation of irritant 
vapors, by the swallowing of irritant fluids, as the result of 
burns or scalds, or occurring in the exhibition of renal symptoms 
or other organic lesions, may ofttimes be averted by it without 
resort to tracheotomy. Certain slowly progressive stenotic condi- 
tions, as of specific cicatrization, may indicate it. If, however, the 
larynx be the seat of growths, benign or malignant, especially if, 
in the latter case, a laryngectomy is intended, or of morbid process 
requiring cessation of functional activity, the physiological rest of 
the organ had better be obtained by tracheotomy rather than by in- 
tubation. It is an operation suited to those of younger years, and, 
with equal indications for its performance, is to be preferred to 
tracheotomy when the latter must be performed through a short, 
fat, chubby neck. The operation is contra-indicated if the obstruc- 
tion is with reasonable certainty believed to be located or extend 
below the lower end of the intubation tube. Nor must efforts at 
placing it in position be continued if more than a very moderate 
degree of force be necessary to pass it into or through the glottic 
chink. The operation is also contra-indicated during a spasm of 
the glottis. If, however, these occur in paroxysms, with remissions 
of sufficient length to permit it, intubation is most emphatically 
indicated during an interval. It is not an operation suited for the 
removal of foreign bodies. 

Instruments. — For this operation a special set of instruments 
and tubes is required; O'Dwyer's is preferable (Fig. 253). These 
comprise an introducing instrument, an extracting instrument for 
withdrawal of the tube, and a set of tubes with their proper gauge. 
In addition, a stout, self-retaining mouth-gag, some strong and fine 
braided silk, strips of rubber or adhesive plaster, open finger-stalls 
or a silk handkerchief for protection to the operator's fingers, and 
some sort of protective mask for the mouth and nose should be at 
hand. Sufficient instruments for the performance of a rapid tra- 
cheotomy should be held in readiness for any sudden emergency. 
The tubes are in sets and accompanied by a gauge denoting sizes 
for each age. In shape, the shaft of the tube may not inappropri- 
ately be likened to a spindle laterally compressed, with a median 
symmetrical bulge and with the lower end cut square off and the 
edges rounded. The upper end is expanded into a flat collar, with 
bevelled upper surface to permit better relationship with the epi- 
glottis, and the edges are carefully rounded ; in short, the usual 
shape of the entire tube may be compared to an inverted hoof and 
foreleg of a horse, from the knee down. Special forms are made — 



INSTRUMENTS. 



779 



all, however, modifications of .the primitive shape and too varied 
to permit of description here. The lumen of the tube is elliptical 
in section, and is filled by a blunt rod or obturator, jointed and 
provided with a screw top, the whole being ingeniously arranged 
to support the tube in introducing it, and yet to be quickly released 
and withdrawn by the introducing instrument. Through the collar 
of the tube there is a smooth perforation intended for the passage 
and retention of the braided silk, to act as a safeguard against 
sudden slipping of the tube downward. The introducing instru- 
ment consists of a curved staff, fitted at its distal end with a screw 
thread to attach the obturator, and provided with a sliding appa- 




Fig. 253.— O'Dwyer's intubation set. 

ratus, worked from the handle, for its release. The withdrawing 
instrument is simply a long, curved forceps, fitted with a pair of 
small, broad blades at its extremity, and worked from the handle. 
The blades are introduced closed within the tubal opening, opened, 
and by pressure against the inner surface of the tuber exert suf- 
ficient friction to permit traction on the tube and its withdrawal. 
The gag should be of sufficient size to hold the mouth open to its 
widest extent, but otherwise needs no comment. An equally good 
tube, which is a modification of the O'Dwyer tube, has been intro- 
duced by Max Thorner (Fig. 254), and is described by him as 
follows : 

" In demonstrating a set of instruments which may be called 



780 



INTUBATION OF THE LARYNX. 



improved instruments, I wish to state that I do not think the word 
' improved ? could possibly be applied to the method of intubation 
itself; for when Joseph O'Dwyer gave his great invention to the 
world he had for five long years worked at it at the New York 
Foundling Asylum with such assiduity that the method was then 
■well-nigh perfected. Indeed, all possible objections and obstacles 
had received so much of his thought that little, if anything, has 




Fig. 254.— Thorner's improved O'Dwyer's set. 

to be added, that was of importance, to the original communica- 
tions of the inventor. However, those who have used the method 
a great deal have suggested from time to time that it might be 
possible to overcome some of the difficulties in the manipulation 
of the instruments used for intubation by making certain changes 
in them, whereby the method would be more facilitated. This 
would not in any way diminish O'Dwyer's immortal merit nor 
influence the characteristics of his method. On the contrary, it 
was likely to advance its usefulness and appreciation of its value, 



INSTRUMENTS. 781 

for no one would think it worth while to make efforts at improving 
a thing of little or no value. 

"All of those who have had some experience, or, I should 
rather say, a great deal of experience, with intubation, know that 
at times the manipulation of the instruments may become quite 
difficult. One of the troublesome features is that one needs two 
separate instruments for either introduction or extraction of the 
tube. In addition, the introducer is, as you all know, quite a 
complicated instrument, the terminal screw of which frequently 
does not hold the tube firmly in the right position. Another dis- 
advantage is that each of the six tubes requires an obturator of its 
own, and it not infrequently happens that the old obturators do not 
always exactly fit new tubes of the same size. The old extractor 
is likewise a complicated instrument, and everybody knows that it 
is not always easy, even for expert intubators, to remove the tube 
with the aid of it. 

" It has been attempted at a very early day to overcome some 
of these difficulties by some alteration in the instrumentarium. 
One modification in the extracting apparatus, which is used a 
great deal, is that of Dillon Brown, which consists of a hook 
fastened to a thimble and a ring, attached to the upper end of the 
tube. By this means, with the thimble placed on the right index 
finger, the tubes are extracted. However, there have been a great 
many attempts to combine the introducer and extractor into one 
instrument and to do away with obturators, the latter having 
often been the cause of great annoyance to the operator and of 
danger to the patient. A good many different instruments have 
been invented for this purpose, the description of wdiich I will 
omit. 

" The greatest advance was made in the instrument of Ferroud, 
which I show here, and which is rather complicated, as it consists 
of seven distinct parts which cannot be readily taken apart. On 
the principle of this instrument, an introducer and extractor com- 
bined has been constructed by a Chicago firm, 1 which surpasses, in 
my opinion, all former attempts at simplifying these instruments. 

" The instrument which serves as introducer and extractor (Fig. 
254, 1) has at its extremity two serrated beaks (a) about two inches 
long. They are opened by pressure with the thumb on the upper 
portion of the lever (6), and are automatically held open by a 
ratched arrangement, while pressure with the index finger upon 
the lower end (6) of this ratched bar relieves it and closes the 
beaks. By firm pressure the beaks hold the tube immovably, so 
that it cannot slip off nor turn during an attempt at introduction 
or extraction. This whole instrument consists of only two parts — 
the handle with one beak and the lever and ratched arrangement 
with the other beak (6 and a) — which two parts are readily taken 

1 Frank and Kratzmueller, 56 Dearborn Street, Chicago, 111. 



782 INTUBATION OF THE LARYNX. 

apart by screwing the thumb-screw (c) toward the right. This 
screw has the further advantage of being so fastened to the instru- 
ment that it cannot be removed from the shank of it by unscrew- 
ing it in either direction, and therefore cannot be lost at a time 
when such a loss would frequently cause a very disastrous delay. 

" The tubes also have been slightly modified. While the gen- 
eral configuration of the tube is an exact reproduction of the orig- 
inal O'Dwyer tube, the top of it has been slightly changed, in that 
the opening has received a funnel shape, slanting from the edges 
of the rim of the tube toward the center. This facilitates the 
introduction of the beaks greatly when the tube is in the larynx, 
inasmuch as it allows the beak to glide from any point of the rim 
almost automatically into the opening, and what this means can 
be appreciated by those who have had experience with the old 
extractor. Another change that the tubes have received is that 
the lower end has been cut off at an angle of about forty-five 
degrees, slanting from right to left. This facilitates the passage 
of the tube between the vocal cords and at the same time will 
prevent injury to the tissues, as the knob of the obturator, which 
in the original tubes closes their opening, is absent in these. The 
absence of the obturator and its knob has the additional advantage 
that air passes through the tube along the side of and between 
the beaks of the introducer during and immediately after intro- 
duction — a fact which contrasts with the absolute obstruction to 
breathing while the obturator of the old instrument is in the tube. 
Therefore, with this instrument the operator need not be in such 
a hurry to introduce the tube and to withdraw the obturator. 

" A mouth-gag is furnished with this set of instruments which 
differs from the one usually found in the set of O'Dwyer's instru- 
ments. 1 It consists of a wedge-shaped mouth-piece, which is fast- 
ened to two steel rings by the aid of a curved bar (Fig. 254, 3). 
In using it the assistant puts two fingers of his left hand through 
the rings, places the wedge-shaped mouth-piece, which is well cov- 
ered with rubber tubing, between the left molars, and keeps the 
left hand firmly pressed against the cheek of the patient. In this 
manner he not only keeps the mouth opened, but also steadies the 
head of the patient at the same time. 

" It can be readily seen that the method of intubation has not 
been altered in any degree by the use of these instruments, which 
will appeal to many as simplifying the manipulation to a great 
extent. 

" In conclusion, it may be added that the old tubes can be used 
with this new introducer and extractor as well as the new tubes." 

Position of the Patient and Operator. — In the perform- 
ance of this operation the majority of operators place the patient 
upright, the arms confined by a sheet wound around the body, and 

1 This mouth-gag was devised by Dr. Henrotin of Chicago. 



POSITION OF THE PATIENT AND OPERATOR. 783 

an assistant seated in a chair holding him immovably in the grasp 
of his knees and arms. A second assistant steadies the head from 
behind and at the same time makes strong vertical extension of the 
neck. The gag is placed, the operator introduces the forefinger 
of his left hand, guarded by the finger-stall, back in the mouth in 
the median line to the epiglottis, hooks it up, and holds it steadily 
lifted by slight lateral pressure on its edge. The tube, mounted 
on the introducer, is then passed carefully back in the median line 
to the top of the left forefinger, taking care to avoid touching sen- 
sitive areas, and keeping the handle of the introducer well depressed 
toward the patient's chest. Its end having reached the finger-tip, 
the handle is elevated, the end of the tube carefully guided into the 
larynx (Fig. 252), the obturator released and withdrawn with the 
introducer, the tube gently pushed into its place by the finger, 
and the loop of silk either fastened to a tooth or brought out 
between the teeth and fastened to the ear or around the neck. Of 
course, previous trial should be made to be sure that the instru- 
ment is in working order and the loop of silk properly placed. 
But while this position has been and is used successfully, the 
author has adopted in his own practice a position which has given 
him great satisfaction in operating, and which he finds possessed 
of certain advantages and without some of the disadvantages that 
the other entails. The arms and body of the patient are secured 
by a sheet wound tightly around them, and he is placed on his 
back at the edge of a table in such a manner that the head is 
allowed to hang over the edge and make firm extension on the 
anterior structures of the neck. An assistant on one side of the 
patient, leaning over, holds him firmly by pressure of his shoulders, 
and prevents lateral motion by confining him between his out- 
stretched arms, at the same time using his hands to hold the 
patient's head steadily in place between them. The operator takes 
his seat opposite the upturned face of the patient, inserts the gag 
with the handles turned away from him, and opens the mouth to 
its fullest extent. Using for the purpose a soft handkerchief, the 
tongue is seized by another assistant and drawn forward. Passing 
the guarded left forefinger into the mouth, the epiglottis is lifted 
and held by lateral pressure of the finger. The introducer is 
taken in the right hand, the ends of the silk loop being secured by 
the fingers, and then, observing the same relation between patient 
and instrument as in the upright position, with the extended and 
curved right arm the tube is entered in the median line and 
advanced to the left finger-tip. By thus extending and curving 
the arm the operator may readily keep the instrument in the 
median line, and as he elevates the handle of the introducer in 
passing the tube into the larynx, he both works from himself and 
at the same time brings the handle in easy position to make the 
manipulations necessary to remove the obturator. The end of the 



784 INTUBATION OF THE LARYNX. 

tube having reached the tip of the left forefinger, it is gently 
guided into the larynx, the obturator withdrawn, the tube care- 
fully pushed to its place, the silk loop secured, and the gag 
removed. This method the author finds in his experience to be 
easier in actual performance than when introduction is attempted 
in the upright position. The hard table gives a steady resistance 
of more utility in restraining the violent struggles of a patient 
than does the mere clasp of an assistant's arms. The light in the 
operating field is better and the danger of the tube slipping beyond 
control into the trachea or esophagus is averted. Further, if intu- 
bation should be found not practicable, or if any sudden impera- 
tive necessity arise, the position of the patient is at once available 
for tracheotomy. When the tube is in place, unless very marked, 
or at least sufficient, relief for the safety of the patient does not 
take place, thorough investigation must be made to discover the 
cause. 

Complications, Dangers, and Accidents. — Like all other 
operations upon the respiratory tract, the actual performance is 
more difficult than a written description would indicate. Strug- 
gling and gagging are more or less violent, and in spite of the vise- 
like grasp of the assistants, some sudden movement is almost sure 
to disarrange the relations of the instruments. Sudden slipping 
of the gag may occur during some such movement and result in a 
wound of the operator's hand, even if protected against it, which 
may lead to disastrous results. The operator runs the risk of per- 
sonal infection in eye, nose, or mouth from bits of material expec- 
torated during violent coughing. The tube may be found a mis- 
fit and require a repetition of the process. Or the tube may be 
dropped in the esophagus, or possibly even passed through the 
vocal bands into the trachea — complications which the supine posi- 
tion averts. Glottic spasm may occur sufficiently severe to pre- 
vent entrance of the tube, and even so protracted and severe as to 
demand tracheotomy, Finally, the tube may push ahead of it a 
mass of membrane and occlude the trachea beyond any hope of 
relief except through tracheotomy, or it may become packed with 
shredded membrane, necessitating removal and cleansing. 

Postoperative Care. — A case of intubation, from the inser- 
tion of the tube to its removal, requires careful watching. Sud- 
den blocking, particularly in membranous cases, may occur and 
demand immediate removal and cleansing. The nurse in charge 
must therefore be carefully instructed as to the danger symptoms 
to be observed which demand the abstraction of the tube, and 
shown how to withdraw it by means of the silk loop left in situ. 
Should any hesitancy be noted in the tube leaving its position, 
inversion of the patient must be performed, and the chest and 
back smartly jarred to dislodge it. The tube may be ejected dur- 
ing some paroxysm of coughing, in which case, not infrequently, it 



POSTOPERATIVE CARE; SEQUELS. 785 

will be found on close observation to be no longer necessary and 
may be removed. Or if it become detached from its loop and 
ejected, it may very likely be swallowed, though one need have 
little fear of untoward effects on its intestinal journey. Feeding 
of the patient presents some difficulty. By some patients liquids 
may be readily taken after a few preliminary efforts have been 
made. By others semi-fluids can be readily ingested, while still 
others may only be able to take milk or other fluids from an ordi- 
nary nursing bottle while lying with the head below the level of 
the body. In some cases efforts at feeding seem impossible, and 
the stomach-tube or rectal alimentation may be necessary. Thirst 
may be assuaged by the sucking of small pieces of ice or the use 
of small rectal injections of water. If, however, it becomes evi- 
dent that nutrition is failing under the use of the tube, tracheotomy 
is to be performed and the laryngeal tube removed. Nor must 
the wearing of an intubation tube be in any case considered as in 
any way precluding the continued use of the general and local 
measures which exert a beneficial influence on the process present, 
and these must be rigorously maintained. The position and free- 
dom of the patient are to be modified only as the general course of 
his disease may demand. 

The removal of the tube is sometimes a matter of more dif- 
ficulty than its insertion. It may be ejected by the patient during 
a coughing paroxysm, and in such a case it may not be necessary 
to reinsert it. Careful watch must be kept on the respiration, and 
at the evidences of recurrent dyspnea the tube must be replaced. 
In removal of the tube for any cause temporarily, or to test the 
need of its further presence, the introducing instrument must be 
in readiness for its immediate replacement. If the tube is to be 
removed by the extractor, the same directions as for its insertion 
are to be followed, the closed blades of the extractor being passed 
to the glottic opening under the guidance of the finger-tip, the 
blades inserted into the tubal opening, separated, and the tube 
carefully withdrawn. 

Sequels. — Following the wearing of the tube there is usu- 
ally a paretic condition of the vocal cords which ultimately dis- 
appears. Rarely, cartilage-erosion takes place from the pressure 
of a tube. 

50 



CHAPTER XXIII. 
TRACHEOTOMY. 

Indications and Contra-indications. Low Tracheotomy. 

Operative Procedure. Laryngotomy. 

Instruments. Complications and Dangers. 

High Tracheotomy. Postoperative Care. 

Definition. — By tracheotomy is meant the incision of the 
trachea and the establishment, by means of tubes or otherwise, 
of an artificial patulous opening of more or less permanency. 

The same procedures upon the larynx are termed laryngotomy, 
thyrotomy, thyroidotomy, etc., according to the site of the incision. 

Indications and Contra-indications. — Prominent among 
these is the dangerous occlusion of the larynx by the membranes 
of diphtheria or croup, especially if the dyspnea be so severe as to 
cause recession of the softer tissues of the chest in inspiratory efforts. 
In these cases, unless intubation is practicable and affords marked 
relief, tracheotomy should be performed. The operation is often 
indicated in cases of edema of the glottis and periglottic tissues, 
whether caused by ammonia or other irritating liquids or gases, 
scalds or burns, or by some more distant lesions. Certain trau- 
mata at the base of the tongue and the pharynx, as well as laryn- 
geal fractures, may demand it. Protracted spasmodic seizures 
of the larynx may cause dyspnea sufficiently severe to indicate it. 

Tubercular laryngitis, especially if attended by much adjacent 
tumefaction of tissues, and the progressive stenosis of syphilis or 
its obstructive gummata may require it. The same is true of 
obstruction from certain laryngeal neoplasms, external pressure, 
and inoperable malignant disease. Finally, the presence of foreign 
bodies in the air-passages, which defy efforts at removal through 
the pharynx, is the cause of a goodly share of the total number of 
the operations performed. 

The operation, however, should be doubtfully considered in 
those cases in which intubation of the larynx offers fair chance for 
relief of the dyspnea. It may not be amiss here to caution the 
practitioner against error in attributing dyspnea due to pulmonary 
or other organic lesions to laryngeal or tracheal obstructions which, 
in reality, are not present. 

Operative Procedures. — The proper performance of the 
operation demands that the patient should be placed upon the 

786 



INSTE UMENTS. 787 

back, with the head held in full extension and the structures on the 
anterior aspect of the neck thrown in outline as firm and tense as 
possible. To this end a narrow table is admirably suited, the 
shoulders of the patient being elevated slightly by a firm support, 
the neck resting on a bag of sand or salt placed at the edge of the 
table, and the head hanging over the edge and held firmly in the 
grasp of an assistant's hands or, better, in his forearms, leaving his 
hands free to use the retractors. The limbs are to be restrained 
by the use of cloth bandages or the hands of assistants, and all 
sudden motions of the patient are to be guarded against as far as 
possible. The best light attainable is to be thrown on the site of 
incision, and care must be taken that it is not so placed as to be 
darkened or impeded by the hand of the operator. General anes- 
thesia may or may not be employed, according to the circumstances 
of the case or the peculiar conditions demanding operation. If 
ether rather than chloroform is to be used, it is to be chosen only 
after consideration of its probable irritant and spasm-producing 
effects upon the laryngeal structures. The hypodermic use of 
local anesthetics, such as cocain, eucain, and the like, must be 
guardedly advised, in view of the vascularity of the region and its 
close proximity to the heart. Pain, however, after the skin is cut, 
is slight, and dermal anesthesia sufficient in extent and duration 
to incise the superficial tissues is readily obtained by the freezing 
spray. The site should, of course, be prepared, if possible, with 
the usual surgical precautions. 

Instruments. — The surgeon should have at hand, if possible, 
the following instruments : A narrow-bladed scalpel, a dry (Allis) 
dissector, grooved director, two small, flat-bladed retractors, two 
blunt hooks or aneurysm needles, a tenaculum, dissecting forceps, 
hemostats, a sharp bistoury or tenotome for opening the trachea, 





' ' :^C L 




Fig. 255.— Keen's silver tracheotomy tube. Fig. 256.— Richard's tracheotomy tube. 

and one with a blunt point to enlarge the incision, if necessary, sev- 
eral sizes of tracheotomy tubes with tapes, a tracheal dilator, tracheal 
forceps, and a curved needle threaded with a stout ligature. 
Sponges, feathers, bent-wire retractors, flexible catheter, mouth- 
gag, and an alkaline solution for membrane if present are needed. 
A cautery might be of use in severe hemorrhage, and a basin of 



788 



TRACHEOTOMY. 




Fig. 257.— Cohen's trachea tube. 



cold water should be at hand for affusion upon the chest, if respi- 
ration is retarded after the operation. The variety of tracheotomy 
tubes that can be used is extensive, and their selection is largely 
a matter of personal choice. Figs. 255-257 can be adapted to 
most any case. The principle, however, which gives the most 
satisfaction is that of a curved tube fitted with an inner and 

removable second tube. The first 
or outer tube is made of various 
metals, preferably silver, for its 
bactericidal action, or rubber, and 
has a movable collar, which in turn 
fits a flange sufficiently broad to 
fit the neck comfortably, and pro- 
vided with appropriate means for 
its retention in situ. A size should 
be used as large as is compatible 
with freedom from irritation and 
strain upon the trachea. 

The operation may be per- 
formed at different levels of the 
neck, the isthmus of the thyroid 
gland furnishing a definite anatomical division between them. 
Thus, if the trachea be opened above the level of the middle of 
the thyroid isthmus, the procedure is termed high tracheotomy ; 
and if the incision be extended upward so far as to divide the 
cricoid cartilage, whether unintentionally, as sometimes happens, 
or with the full intention of the surgeon to do so, the operation is 
properly termed laryngotracheotomy. If, however, the trachea be 
opened by an incision extending downward from the mid-level of 
the isthmus, it is termed a low tracheotomy. 

Of these operations, the high tracheotomy is the more easily 
performed, because of the more favorable anatomical relations, 
and is the operation preferred by the surgeon for the majority of 
cases. Low tracheotomy is, however, more advisable in certain 
cases of foreign bodies and where it is desired to maintain a per- 
manent opening. 

High Tracheotomy. — The patient being in the position 
described, the surgeon takes his stand, either behind or at which- 
ever side best suits his convenience. The prominence of the 
thyroid cartilage is noted, and below it the cricoid. If possible, 
the course of the anterior jugulars should be determined prior to 
their possible encounter in the incision. Then steadying, if neces- 
sary, the structures of the throat with his free hand, with his 
unsupported, armed hand the first incision is made, extending 
from about the level of the cricoid to an inch and a half or two 
inches below and exactly in the median line. The skin being 
opened, any presenting veins should be pushed aside or tied off 



LOW TRACHEOTOMY. 789 

and cut, the superficial fascia opened to the same extent upon 
the grooved director, and the deep fascia exposed. This is opened 
in the same manner and to the same extent, and the presenting 
veins, as before, are either pushed aside or tied off and cut. The 
intermuscular interval between the sternohyoids and sternothyroids 
is now located and carefully opened by a blunt dissector. This 
being done, the edges of the opening made so far must be kept 
carefully apart by means of blunt retractors reaching to the bottom 
of the wound. Too much care in placing and supporting these 
cannot be taken, both to avoid the very possible danger of mis- 
leading the surgeon's knife through a malplacement of the trachea 
and to minimize the amount of pressure upon it. The floor of the 
opening should now be formed by a layer of the deep cervical 
fascia, which in this region splits to enclose the thyroid isthmus, 
and more or less of the latter structure may be easily outlined or 
found bulging into the wound. The fascia is to be opened on a 
grooved director and the isthmus drawn downward by a blunt 
hook or small retractor. In case the isthmus fills too much of the 
wound to be so treated, a short transverse incision over the cricoid, 
not over one-half inch in length and through the fascia, may be 
made, and fascia and isthmus may be together stripped up and 
drawn downward. A quantity of loose connective tissue just 
overlying the trachea must be cleared carefully away and the 
cartilaginous rings plainly exposed. The trachea thus cleared, a 
tenaculum hook is fastened in the cricoid cartilage and held to 
steady the trachea. The knife is then to be so guarded by the 
forefinger as to prevent too deep a cut and posterior transfixion, 
and with its back to the sternum is to be inserted in the trachea 
above the isthmus in the middle line, while the two or three rings 
above it are to be opened by an upward cut. Care must be taken 
that, if a membrane be present in the trachea, it is opened also, 
lest it be forced downward by the knife. The opening made, 
there is usually more or less coughing, with ejaculation of bloody 
mucus and the like. This being cleared away, the edges of the 
wound are to be grasped with dissecting forceps and held open, or 
a dilator inserted for the same purpose, the trachea cleared, as far 
as possible, of mucus and noxious material, the tracheotomy tube 
inserted, the tenaculum removed, and the tube tied in by tapes 
passed around the neck and tied on one side. Suture of the wound 
below the tube may be performed. Or if the so-called operation 
without tubes be intended, blunt-retractor hooks are inserted and 
attached to the appropriate elastic neck-band necessary to keep the 
opening patulous ; the edges of the cut are sutured to the skin, or 
an oval or diamond-shaped portion is removed, its long axis coin- 
cident with that of the trachea, according to which of these three 
methods the operator prefers. 

I<OW Tracheotomy. — Low tracheotomy requires practically 



790 TRACHEOTOMY. 

the same technic as the high operation. The skin-incision is made 
in the middle line, and extends from just below the cricoid car- 
tilage nearly to the manubrium. The fascial layers are lifted by 
the grooved director and opened carefully, veins and small arterial 
branches being pushed aside or tied off and cut. The intermus- 
cular space should be cleared and the thyroid isthmus be drawn 
upward by a blunt hook. Or it may be necessary, both in the 
high operation and the low, to pass a stout double ligature under 
the isthmus, tie, and cut between on the median line. In this 
lower site, also, the thyroidea ima artery must be kept in mind, the 
occasional height of the innominate artery to as far as the eighth 
or seventh tracheal ring, and the inverse ratio in the size of the 
thymus gland to the age of the patient. The remaining steps in 
the procedure do not differ from those already described under 
High Tracheotomy. 

I/aryngotomy. — This operation, owing to the superficial loca- 
tion of the cricothyroid membrane and the absence of vascular 
structures of importance, is the quickest and the least dangerous 
of the operative procedures upon the air-passages. The mem- 
branous interval between the thyroid and the cricoid is located, 
and a median vertical incision is made through the skin and 
fascia ; the sternohyoid and sternothyroid muscles are separated, 
and the cricothyroid membrane is opened by a transverse cut close 
to the cricoid border. The transverse incision is so placed as to 
avoid the small cricothyroid artery, and is to be made with a sharp 
knife, carefully guarded by the surgeon's forefinger, as in trache- 
otomy. A tube may be inserted, preferably shorter than that used 
for tracheotomy, or the wound may be kept open by retracting 
hooks, or allowed to heal by granulation, if its purpose be served. 
This measure is preeminently an immediate emergency operation, 
and one the few details of which should be thoroughly known by 
every practitioner. It should not be attempted on a patient under 
thirteen years, because of the small size of the cricothyroid space 
previous to that age. t 

Operative Complications and Dangers. — The opening 
of the trachea while intrinsically not a formidable operation, may 
nevertheless be seriously complicated and filled with danger in its 
performance. While undue haste is to be heartily condemned, yet 
so varied are the exigencies indicating the operation, that life may 
demand the hurried knife-thrust, with no other preparation than a 
hasty palpation of landmarks. The incision necessary is in many 
cases difficult to make from the almost uncontrollable tracheal 
movement in the violent inspiratory efforts of the patient. Hem- 
orrhage is apt to be severe from the engorged veins so abundant 
in this region, though, happily, this complication lessens with the 
free establishment of respiration. Sudden and severe hemorrhage 
may follow a chance cut of the thyroid isthmus, and require rapid 



POSTOPERATIVE CARE, DANGERS, AND COMPLICATIONS. 791 

use of the hemostatic forceps. The retractors may be wrongly 
placed or slip from position, causing a dangerous lateral dissection 
back even as far as the vertebral column, and attended by danger- 
ous pressure on the trachea or injury to the post-tracheal structures. 
In incising the trachea, if a membrane be present, the latter may 
be pushed ahead of the knife without being penetrated, thus either 
defeating the relief of the dyspnea, or aggravating it by packing 
the membrane in the lumen of the tube. Such an accident 
demands the prompt use of tracheal forceps (Fig. 258) and the 




Fig. 258.— Trousseau's tracheal dilator. 

scissors or knife. Again, an incautious use of the the knife may 
cause the posterior wall to be wounded, or even penetrated and 
opened into the esophagus. The trachea may be clogged by mucus 
or blood and mucus, or blood may have entered with the incision 
and demand a clearance. If so, the Trendelenburg position, or 
semi-inversion, is of prime importance, coupled with the prompt 
use of means to keep the opening patulous and expel the material. 
Aspiration of the wound by the mouth is inefficient, and in infec- 
tious cases highly dangerous. The insertion of a flexible catheter 
is of value, and it may be attached to an aspirating bulb or, 
better still, may have air blown strongly in it. It should be 
inserted so far as to form a channel to the lungs, if possible. 
Sudden cessation of respiration may occur both before and after 
the actual incision has been made. If incomplete, the tracheal 
opening must be made at once and cleared, and efforts at restora- 
tion of respiration be immediately performed. Hot and cold 
affusions to the chest, sharp slapping of the back or buttocks, 
and artificial respiration are indicated. Fortunately, the cessation 
is but momentary in the majority of cases, and the function readily 
restored. 

Postoperative Care, Dangers, and Complications. — 
Upon this, fully as much as the operation, depends the success of 
the object sought. If the operation has been successfully per- 
formed — as, for example, for the removal of a foreign body — and 
there exists no reason for a further use of the opening, the wound 
may be cleansed thoroughly with corrosive-sublimate solution, 
protected under a moist aseptic or antiseptic dressing, and allowed 



792 TRACHEOTOMY. 

to heal by granulation. If, however, there is any reason to antici- 
pate, from the irritation of the operative measures employed or 
the condition present, a sudden edema of the laryngeal or glottic 
structures, a tube must be inserted, or the wound kept patent by 
the use of retractors and tapes until this danger is past. Anti- 
inflammatory drugs should be administered, cough quieted by 
some sedative mixture, and the patient kept quiet in the recum- 
bent position. Healing is usually fairly rapid, but care must be 
taken that drainage is free. The care of a patient in whom the 
opening is to be maintained, either by tubes or without, is more 
complex. The room must be at an even temperature of between 
75° and 80° F., without draughts, and the air must be moistened. 
This may be done either by boiling water and allowing the steam 
to permeate the air or by slacking lime in a suitable vessel. If 
necessary, a tent of sheets or of blankets may be constructed over 
the bed to confine the vapor better. Feeding is usually not dif- 
ficult. Rectal alimentation may in some cases be necessary, and 
at times the stomach-tube. Attention must be paid to the kidneys 
and bowels, and above all the insurance of sufficient sleep and 
rest must be obtained. Nor must the usual systemic and local treat- 
ment of the existent condition be discontinued after the operation. 
If a tracheotomy tube be used, the patient must be carefully 
watched and prevented from pulling it out, especially while com- 
ing out of ether, and afterward if he be not old enough to under- 
stand its use. A light piece of gauze or fine muslin is to be damp- 
ened and kept before the tube, as a strainer for dust. The tube 
must be kept clear, and this will require a varying amount of 
attention, according to the condition present. In croup, etc., the 
tube should be cleared at very frequent intervals, the tube being 
cleansed with an alkaline fluid and a feather. This may need to 
be done every half hour, and not infrequently the inner tube must 
be withdrawn for sudden blocking by a piece of detached mem- 
brane. The cannula should also be cleansed by an alkaline solu- 
tion, and must not be left too long without its inner tube f A bet- 
ter plan is to have two of the latter and use them alternately. In 
membranous cases, also, blocking may occur by a piece or roll of 
the membrane which cannot be removed through the tube, and 
may necessitate the withdrawal of the whole apparatus and the use 
of the tracheal dilator and the tracheal forceps — instruments which 
should be always at hand. The nurse should also be warned of 
this possibility and instructed how to withdraw it, remove, if neces- 
sary, the- impacted membrane, and keep the opening patulous by 
retractors until the surgeon arrives. The replacement of the tube 
before the wound has healed sufficiently to form a canal for it 
requires some skill ; but after the wound has so healed, about the 
third day, it is a comparatively simple matter. Every two or 
three days the outer tube should be withdrawn, spots of discolora- 



POSTOPERATIVE CARE, DANGERS, AND COMPLICATIONS. 793 

tion from possible sloughing areas noted, and the areas touched 
by silver nitrate, the wound cleansed, and the tube cleansed and 
replaced. The length of time the tube is to be left in situ varies 
with the nature of the case and the object of the surgeon. In 
membranous cases from eight to fifteen days are usually required, 
the time of removal being indicated by the progress of the condi- 
tion and the respiratory ability, as shown by stopping the end of 
the tube momentarily with the finger. After its removal the canal 
formed usually closes in and heals kindly by granulation, a few 
thicknesses of gauze being kept over the opening until it closes, 
when a firmer dressing may be applied. In some cases, however, 
there is difficulty in removal of the tube permanently, especially 
in young subjects, because of structural changes in the vocal cords, 
paralytic conditions of the laryngeal mechanism, or stenosis of the 
trachea. Granulation-tissue in the larynx or trachea may also pre- 
vent it. In these cases the tube must be worn until proper local 
treatment has remedied the obstructive cause. In any case, after 
removal of the tube the surgeon must stand prepared to reinsert 
it, until a reasonable lapse of time shows its needlessness. 

The care of cases without tubes is practically the same, the 
opening being kept as clear as possible and protected by moist 
gauze lightly over it. Cicatrization proceeds somewhat slowly 
because of the preventive measures used to keep the opening 
patulous, and it may be necessary, from time to time, to press the 
edges apart or slightly nick them. 

Postoperative complications sometimes occur, the most impor- 
tant being undue sloughing of the wound from pressure, cellulitis, 
emphysema, and edema of the cervical tissues. Secondary hemor- 
rhage is not unknown, and has proved fatal in a few instances. 
Erysipelas may develop, as well as diphtheritic infection of the 
wound. Exuberant granulations may occur, and sometimes of 
such size as to be termed vegetations. Sloughing of the tracheal 
cartilages is not so likely to occur, but does occasionally take 
place. 



CHAPTER XXIY. 
SURGERY OF THE LARYNX. 

Major surgery of the larynx is dependent upon one of two 
conditions : intralaryngeal lesions interfering with respiration, or 
extralaryngeal lesions that, from pressure, involve the larynx and 
necessitate surgical interference. 

The radical surgical procedures, such as thyrotomy or laryn- 
gectomy, are usually necessitated by the presence of tumors either 
benign or malignant, although injuries such as gunshot wounds, 
laceration with destruction of tissue, or foreign bodies, may neces- 
sitate partial laryngectomy or thyrotomy. 

The presence of tumors in the larynx is the common cause of 
surgical interference with this organ. The most important feature, 
then, is the diagnosis, and upon the diagnosis depends the selection 
of the operation — thyrotomy or laryngectomy. If the growth is 
nonmalignant, a purely benign growth, thyrotomy should be per- 
formed, taking it for granted in this chapter, that all growths are 
of sufficient size to prevent or exclude the possibility of their re- 
moval by intralaryngeal operations. 

The early diagnosis is of vast importance, but frequently the 
patient does not present himself for examination until the condi- 
tion has existed for many months and the structures are then 
extensively involved. In the early stage of any intralaryngeal 
growth, where the lymphatics are not involved and where the 
tumor is of small size, a careful study of the case is requisite and 
the "snap" diagnosis should never be made. The case should be 
observed from day to day and a diagnosis made by exclusion. I 
have seen a number of cases that clinically had every appearance 
of malignancy, the age of the patient being in favor of this diag- 
nosis, but on studying the case and establishing a diagnosis by ex- 
clusion, in a number of instances the tumor has proven to be 
nothing more than a tertiary syphilitic manifestation. 

Medicine, of course, will have no permanent effect on a benign 
or malignant growth. The age of the patient, the presence or 
absence of inflammatory areas around the tumor, the amount of 
edema, the structures involved, the slow growth or the fulminating 
form, the involvement or noninvolvement of the lymphatics, 
the general health of the patient, the family history, the habits, 
the general morale of the individual, should all be carefully con- 
sidered before making a diagnosis which necessitates probably a 
radical operation. In other words, care and conservatism should 

794 



SURGERY OF THE LARYNX. 795 

certainly be exercised in giving opinions relative to this important 
organ. 

If the growth is a malignant one and an early diagnosis can be 
made, then thorough eradication should be performed, but an in- 
nocent larynx should not be sacrificed until such a diagnosis is 
established beyond doubt. Where the tumor can be thoroughly 
removed by thyrotomy (and such can be done where there is no 
glandular involvement in nonmalignant cases), this certainly should 
be practised before the more radical operation of laryngectomy 
should be performed. On the other hand, if the growth is not 
only intrinsic, but extrinsic, and there is extensive glandular in- 
volvement, and the diagnosis of malignancy is established beyond 
doubt, in such cases it will be almost impossible, even by perform- 
ing a complete laryngectomy, to remove the entire growth ; in other 
words, to get beyond the spread of the disease. 

The much mooted question of whether a benign growth be- 
comes malignant, I think has long ago been settled beyond any 
doubt. Tissue never changes type, and you might as reasonably 
expect chicken-pox to turn into typhoid fever as to expect a benign 
growth to change its type. To be sure, a benign growth may be 
the site of a malignant growth, but the tissue does not change its 
type and one turn into the other. A benign tumor, either epithe- 
lial or connective, has its type in adult connective tissue and ful- 
fills that type up to the point of physiological function, failing only 
in this particular. It is then a little lower grade type of connec- 
tive tissue than the original, hence it would predispose that part 
more than the original structure, so that the embryonic or malig- 
nant type of tumor would find a more suitable nidus for prolifer- 
ation in this rather low-grade adult tissue. 

A word as to microscopic examination before operation. If 
sufficient tissue is removed to show the entire structure of the 
tumor, a microscopic examination will certainly aid in the diag- 
nosis, but frequently a mere portion is pinched off, and this portion 
is taken from the surface of the tumor. Certainly an erroneous 
microscopic idea would be obtained. The illy-formed tissue, the 
inflammatory cells, the altered epithelial cells, would mislead the 
microscopist primarily and the surgeon secondarily, but unfortun- 
ately the patient would be the one who would suffer. If the diag- 
nosis of malignancy, then, is clearly established beyond doubt, the 
radical operation should be performed. If not, I certainly w r ould 
advise the less radical measure. 

The early diagnosis of laryngeal cancer or any form of malig- 
nant growth is then of the greatest importance from a curative 
standpoint. Unfortunately, the early symptoms are not alarming, 
and the patient suffers practically no inconvenience and has really 
no constitutional symptoms. In many cases the growth has been 
in progress for many months before the patient consults the phy- 



796 SURGERY OF THE LARYNX. 

sician. However, if seen in the very early stages, diagnosis is 
extremely difficult, and no surgeon wishes to needlessly sacrifice 
the laryngeal structures and subject the patient to the danger and 
risk of such a grave operation unless the diagnosis is fully estab- 
lished. For that reason I certainly urge a careful and deliberate 
study of the case and that the diagnosis should be made largely by 
exclusion. 

Operation on the I^arynx. — Dangers. — In a general way 
shock, hemorrhage, sepsis, and aspiration pneumonia are the prin- 
cipal dangers. Shock can be prevented somewhat by the prepara- 
tion of the patient before the operation. Hemorrhage usually can 
be controlled during the operation, and by this control the 
danger of shock is lessened. However, if severe hemorrhage 
should take place, instantly the patient should be transfused with 
the normal salt solution. To prevent sepsis or the drawing of 
blood into the lungs the trachea should be packed either by 
Gerster's, Trendelenburg's, or Hahn's cannula, or an ordinary 
cannula surrounded by gauze. 

As stated elsewhere, I certainly advise the preliminary trache- 
otomy, as I think it overcomes, to a great extent at least, a 
certain amount of shock ; besides, if done ten days or two weeks 
before the major operation, the patient will have become accus- 
tomed to this manner of breathing, and also the mucous membrane 
will have adapted itself to the practically direct entrance of air. 

THYROTOMY. 

The splitting of the thyroid cartilage and the removal of neo- 
plasms by excision and thorough curetment have been followed by 
considerable success in many instances, especially if the growth is 
unilateral. The thyroid cartilage being so closely connected with 
the cricoid and hyoid it will be usually necessary to divide both. 
The mucous membrane and soft parts should be sutured ; also the 
skin. If these sutures hold the cartilage in position, it will not be 
necessary to suture the cartilage. 

The after-treatment is practically the same as in the com- 
plete operation. The trained eye of the surgeon will tell him 
to what extent the tissue has been invaded ; and the advantage 
of thyrotomy is that, after splitting the larynx, if in the judgment 
of the surgeon all the diseased tissue can be removed and the 
larynx saved, then the operation of thyrotomy will be all that is 
necessary. However, if in his judgment the tissues are deeply 
involved, then the operation of thyrotomy can be converted into 
one of laryngectomy, complete or partial. 

Indications. — Foreign bodies which cannot be removed by 
intralaryngeal method, nonmalignant tumors, partial necrosis, and 
stenosis are indications necessitating this operation. 



LAB YXG ECTOM Y. 797 

Palliative Tracheotomy. — In both operable and inoperable 
cases palliative tracheotomy may be performed. In fact, I am 
convinced that if the operation of laryngectomy is necessitated, if 
preliminary tracheotomy has been performed and the patient accus- 
tomed to breathing through the tracheotomy-tube, there will be 
less shock during the major operation. In inoperable cases, 
where the larynx is largely obstructed, low tracheotomy will cer- 
tainly afford the patient considerable relief. 

LARYNGECTOMY. 

The indications are as follows : any obstructive lesion located 
within the larynx and involving the laryngeal structure, intrin- 
sic and extrinsic ; extensive necrosis of the structure, regardless of 
cause. 

General Preparation of the Patient. — First, the general 
observation made before giving an anesthetic should be made, such 
as looking after the condition of the teeth, to see if there are any 
suppurative processes about the gums or mouth ; in other words, 
every precaution should be taken to prevent infection during the 
time of the operation. It is impossible to render the mucous-mem- 
brane structures antiseptic. However, the external parts should 
be treated the same as before any other surgical operation. 
Usually, in the patient afflicted with malignant disease of the 
larynx the mucous membrane about the mouth and gums is in 
bad condition, many patients suffering from various forms of 
pyorrhea, and this oral sepsis is a source of great danger during 
and following the operation. Any bridge-work about the teeth 
is also a source for infection. In other words, the mucous mem- 
brane of the oral and pharyngeal cavities should be rendered as 
nearly aseptic as possible. If there is any infection of the acces- 
sory cavities or nasopharynx it will unquestionably complicate the 
case, as it is almost impossible to prevent infection from pass- 
ing down into the throat. The regular routine, as to diet, pur- 
gation, rest in bed, etc., should be applied here the same as 
preceding any other operation. The question of anesthesia is 
one to be determined by the operator, the physical condition 
of his patient determining which anesthetic should be used. 
Some advise the use of cocain as a local anesthetic to prevent 
reflex laryngeal cough. Personally, I do not agree with this, as 
the benumbed mucous-membrane surface permits the accumulation 
of mucus within the upper respiratory tract. If tracheotomv 
has been performed beforehand, or even at the time, the anesthetic 
may be given through a long tube attached to the tracheotomy- 
tube. This is a very convenient method, and the anesthetizer and 
operator are not in each other's way. 

It is of extreme importance to have one trained assistant to 



798 SURGERY OF THE LARYNX. 

watch the patient's condition continuously, and every restorative 
means should be placed at his command, to be used at the slightest 
sign of danger. 

Position of the Patient. — All operators do not agree as to 
the best position of the patient. The full Trendelenburg position, 
I think, is the least desirable on account of the tendency to congestion 
of the vessels of the neck. The modified Trendelenburg position, 
I think, is much better. There should be sufficient lowering of 
the head and shoulders to allow the flow of mucus and blood away 
from the lungs. The position suggested by Chevalier Jackson is 
an excellent one, and is as follows : 

" The posture differs slightly from the Trendelenburg, in that 
the shoulders are not supported. The patient is hung by his 
knees ; the legs, flexed at the knee, are strapped to the dropped 
foot-board, which is all that keeps the patient from sliding clear 
off the incline. The head is dropped over the break when the 
head-board is dropped at the moment of incision. If the table 
be of the proper length, as the one I designed, no sandbag 
is needed. The table of the abdominal surgeon is too long in its 
main top portion, requiring more or less of a sandbag to throw the 
neck up prominently. The larger the sandbag, the less steep the 
incline of the trachea, which incline I rely upon, with the aid of 
an active cough reflex, to keep blood, secretions, or pus out of 
the lungs in all tracheal and throat surgery. As to a possible 
argument against this position that in these old patients the 
viscera dangerously crowd the diaphragm, lungs, and heart, I 
would answer that in a patient so feeble no operation at all is 
justifiable/' 

Illumination. — In a well-lighted room, where direct sunlight 
can be obtained, artificial illumination will not be necessary. 
The best artificial illumination to be used, however, is the one 
obtained by the electric headlight, the current being obtained 
either from the battery or street current. 

The Operation. — While this operation can be and has been 
successfully performed, and the patient's life saved and in some 
few instances probably prolonged, yet, if the patient's condition is 
hopeless, his general health so below par that he has no chance 
to survive the operation, I certainly do not believe that the sur- 
geon is justifiable in performing this operation. 

Three different methods have been advocated, and may be fol- 
lowed with perfect safety : The method of Gliick, in which he 
works from above downward, severing the trachea last ; Keen's 
method, without even temporary tracheotomy, in which the 
trachea is severed and stitched to the skin, as the first step after 
baring the trachea and larynx ; and, third, either of the above 
methods in which a preliminary tracheotomy has been done. 

Jackson maintains that the transverse incision is not neces- 



LARYNGECTOMY. 799 

sary if not more than the larynx is to be extirpated. He also 
removes the epiglottis, whether it is involved or not. 

Of the various methods suggested by different operators, in 
each the general underlying surgical principles are practically 
the same. Whatever method is adopted by the operator, this one 
fact should be kept in mind, that the larynx should be consid- 
ered as a tumor to be removed. Complications, involvement of 
structures, extent of the disease, and accidents will necessitate the 
modification of any method. 

In general, the procedure is as follows : 

Incision is made in the median line, extending from the hyoid 
bone almost to the sternum. A transverse incision may be made 
at the upper end. However, in very few instances will this be 
necessary. The soft structures on the lateral walls of the larynx 
down to the second or third ring of the trachea should be freed. 
This should extend to the esophagus posteriorly. If the pre- 
liminary tracheotomy has been performed, the incision should be 
carried down to the tracheotomy opening. If the preliminary 
tracheotomy has not been performed, then the tissues below the 
second cartilage should be separated in front only. If the growth 
involving the larynx and necessitating its removal has not in- 
filtrated these external tissues, the dissection should be made as 
closely as possible to the larynx and trachea. If the external 
structures, however, are involved to such an extent as to necessi- 
tate the removal of a large portion of the structure, certainly 
laryngectomy would offer no relief to the patient, and the 
operation should not be done. A cannula should be inserted into 
the trachea and secured by disinfected tapes around the neck. The 
large-sized ordinary cannula is as good as any. 

After the soft parts are separated from the larynx and 
trachea the larynx should be severed from the trachea. The 
stump of the trachea should then be secured to the skin by a few 
stitches and the cannula placed directly in the opening of the 
trachea. When the operation is completed the stump of the 
trachea is securely sutured. After separating the larynx from the 
trachea by the transverse cut the larynx should be drawn forward 
sufficiently to put the tissues between the larynx and esophagus on 
the stretch. The esophagus should be carefully dissected free 
from the larynx. This can be done by the blunt dissector or often 
by the finger. This structure is dissected loose to the level of the 
arytenoid cartilage, and then the soft parts divided transversely 
and the diseased larynx removed. Care should be taken not to 
buttonhole the esophagus in this dissection. This is likely to 
occur at the level of the cricoid cartilage. Should such an 
accident occur, it should be immediately closed by the buried 
sutures. The upper edge of the anterior wall of the pharynx 
should be sutured closely to the tissues immediately below the 



800 SURGERY OF THE LARYNX. 

hyoid bone, so as to prevent any infection of the wound from the 
mouth. 

The tracheal stump is then secured by suturing to the skin of 
the neck. The entire incision in the structures, excepting the mouth 
of the trachea, should now be closed. The area from which 
the larynx was removed should be lightly packed with gauze to 
insure drainage. 

The question of removal of the epiglottis is not of such great 
importance. If the tissue is involved it certainly should be re- 
moved, but if not involved I think it probably is well to leave 
this structure in place. If it is to be removed it should be done 
before fixation of the pharynx by sutures. 

Special care should be taken in the suturing of the stump of 
the trachea to see that it is permanently secured. The glands of 
the neck should be carefully inspected for any signs of involve- 
ment by spreading of the carcinomatous growth through the 
lymphatic channels. 

The deductions as to advisability of operation and prognosis 
are well stated by Jackson, as follows : 

" 1. The patient with cancer of the larynx must have his dis- 
ease discovered early, else a cure is well-nigh hopeless. 

" 2. If discovered early, the comparatively slight operation of 
thyrotomy will cure. 

" 3. If discovered late, total or partial laryngectomy will prob- 
ably prolong life for a variable period, but recurrence is fairly cer- 
tain, and the short extension of existence lacks many pleasures and 
comforts. 

" 4. The early curable stages of laryngeal cancer are charac- 
terized by nothing but hoarseness, which may disappear and recur. 
Cough, odor, pain, odynphagia, glandular involvement, external 
swelling, emaciation, cachexia, etc., are present only after the 
curable stage is past." 

P&rier's method of laryngectomy, which is an excellent 
one, is as follows : T-shaped incision on the front of the peck, the 
vertical median cut as described for thyrotomy. The horizontal 
cut transversely across the hyoid region. These incisions are deep- 
ened to the cartilages of the larynx. Considering the larynx as a 
tumor to be removed, one strips the muscles from its external 
surface as far as the level of the inferior constrictors of the phar- 
ynx. The larynx thus only remains attached posteriorly to the 
mucous membrane of the pharynx and esophagus and below to the 
trachea, which has not yet been opened. The trachea should be 
separated from the esophagus with the aid of blunt dissector and 
finger, then, a thread having been passed through it with the help 
of a Reverdin needle, it is drawn forward and divided transversely 
through the first ring below the cricoid cartilage, a specially 
large tube being introduced into the stump, through which the ad- 



LARYNGECTOMY. 801 

ministration of chloroform is continued. The larynx is separated 
posteriorly from mucous membrane of the pharynx, and the great 
cornua of the hyoid bone are divided and the epiglottis re- 
moved or left, as condition requires. The tracheal ring is stitched 
to skin, anterior wall of esophagus is similarly fixed to the lower 
part of the thyrohyoid membrane, which has the advantage of 
shutting off the laryngeal wound entirely from the buccal cavity 
and so lessening the risk of secondary infection. Thus he is 
enabled to close the wound pretty completely above the tracheal 
cannula, leaving merely a drainage open to facilitate the escape of 
the liquids which nearly always form after the operation, which 
lessens the risk of infection. 

Postoperative Factors. — Shock, sepsis, and pneumonia are 
the three dreaded postoperative factors. The patient whose 
physical condition is markedly below par (and such would be the 
case in advanced malignant growth of the larynx) would certainly 
be greatly predisposed to these three factors. Hence, the necessity 
of early diagnosis, while the patient's condition is still good. 

Jackson, who has been very successful in performing complete 
and partial laryngectomy, insists on the following postoperative 
care : 

" Most imperative are the orders against the administration of 
morphin or any other sedative that lessens the activity of the 
cough-reflex, which is the watch-dog of the lungs. For the same 
reason the patient must be completely out of the anesthesia before 
the end of the operation, so there will be no postanesthetic 
sleep. Two special nurses, long trained in tracheal work, alter- 
nate duty so that the patient never draws an unwatched breath. 
Either the assistant or surgeon is always within a few minutes' 
call. 

" The foot of the bed is elevated on chairs for the first twelve 
hours, and after that a less elevation maintained only during sleep 
suffices for three days. After the first twelve hours the bed is 
lowered, in a few hours a pillow is given, then more pillows, 
then a back-rest, so that the patient is sitting up in bed at the end 
of twenty-four hours. On the second day he is sitting in a reclin- 
ing chair, and the third day may move about a little. Here, again, 
is seen the absolute necessity of a strong general condition. Syn- 
cope would be frequent and possibly fatal, were a feeble man sub- 
jected to this while being starved." 

As to the question of dressings, the author differs radically from 
other workers. ' : In laryngectomies, thyrotomies, and tracheot- 
omies the dressings are changed every three hours. They are in- 
variably sterile gauze wrung out of mercuric bichlorid, 1 : 10,000. 

" After thyrotomy no tracheal cannula is inserted, but it is in 
readiness, sterilized for immediate insertion if need arise. The 
thyroid cartilage is not stitched, nor the outer wound, except one 
51 



802 SURGERY OF THE LARYNX. 

or two stitches at the upper part if it gape too much. The 
wound is kept open until it heals from the bottom. This in- 
variable rule (to secure union of the divided cartilages first) pre- 
vents exuberant granulations forming on the internal aspect of the 
wound within the laryngeal or tracheal lumen. Dressings wrung 
out of bichlorid solution, replaced every three hours, absorb 
secretions and filter the air which leaks through. 

" Should a tracheal cannula have to be inserted, it is managed 
as after laryngectomy. 

" After laryngectomy the wound above the tracheal cannula is 
drained by a small wick of gauze inserted (not firmly) above the 
cannula and renewed every three hours. The gauze around the 
cannula is renewed as often as soiled, as is also the filter-piece of 
gauze over the orifice. All of these are sterile gauze wrung 
out of weak mercuric bichlorid solution. 

" The inner cannula is dispensed with and the outer cannula is 
replaced by a fresh one every three hours. All of these manipu- 
lations are carried out with the same strict technic as obtains in a 
perfect operating-room. If any one doubts the necessity of the 
frequent dressings or cannula changes, let him smell a dressing or 
a cannula that has been in situ for a day. The laryngectomy 
wound is never packed, as it prevents primary union, which is 
obtainable in more or less of the wound. 

" The mouth and teeth are carefully swabbed every half hour 
with a very cold solution of boric acid in mentholated water. This 
is agreeable and allays thirst. The patient is turned upon his face 
frequently (without pillow) to allow pus and secretions from the 
pharyngeal wound to escape, as screatus is impossible after laryn- 
gectomy. 

" Food, as well as water, must be sterilized by the nurse, whose 
technic equals that of the operating-room nurse. Milk, eggs, 
everything, must not only be sterilized, but must be sterile when 
given to the patient with sterile utensils. 

a After thyrotomy the patient is usually able, within a day or 
two, to swallow normally. A few have been obliged for a few 
days to swallow " up-hill," as after an intubation — that is, supine, 
without a pillow, and with the foot of the bed elevated on chairs, 
and the sterile liquid food being taken through a bent glass tube. 

" After laryngectomy no food or water is given by mouth for 
five days. Unquestionably, thirst can be allayed by enemata. 

" After five days the patient is allowed to swallow sterile water 
and sterile fluid food. If it leak through into the wound, the 
stomach-tube is used. After the eighth day, if leakage persist, 
the stomach-tube is abandoned, and the leak is " corked " from 
below with a small, tight tampon of gauze, placed before and 
removed after eating. Semisolids are permitted after two weeks 
and general diet after three weeks. 



LA E YNGECTOMY. 803 

" During the first few days after laryngectomy vomiting must be 
avoided at all hazards, lest stitches be dragged upon and primary 
union prevented. Hence, the first feeding must be in very 
small quantities, both as to total amount at one feeding and as to 
quantity at each swallow. For the same reason all feeding-tubes 
are to be avoided." 

Artificial I^arynx. — After complete laryngectomy a num- 
ber of cases are recorded in which an artificial larynx was inserted 
with partial success. This can only be done when the stump 
of the trachea terminates internally and is continuous with the 
cavity of the mouth and pharynx. Some cases are on record 
in which the patient was able to develop audible voice after the 
entire removal of the larynx, without any artificial appliances. 

Unilateral or partial laryngectomy is a modification of 
the complete operation, which includes the removal of the lat- 
eral half of the larynx. The same general principles are 
observed as in the complete operation. 

In the very early stages of malignant growth a partial laryn- 
gectomy might be justifiable ; providing such an operation would 
remove all tissue involved ; since you are dealing with a malignant 
condition there is no question about extensive removal of tissue, 
going absolutely beyond any line of infection is the only method 
to be followed. 

Unilateral or partial laryngectomy differs from thyrotomy in 
the fact that a part of the original structures is removed, and only 
differs from the complete in extent. This might be necessitated 
where extensive necrosis had occurred, but usually either the 
operation of thyrotomy or laryngectomy will answer. 

The technic of this operation is practically the same as that in 
complete laryngectomy, except in the amount of tissue removed. 
The procedure is practically the same. I think, however, that if 
partial laryngectomy would eradicate the disease, probably the 
same good results could be obtained by simple' thyrotomy. Per- 
sonally, I certainly believe that if the epiglottis is not involved it 
should be allowed to remain. 



INDEX. 



Abdomtxal muscles in anesthesia, 467 
Abductor paralysis, laryngeal, bilateral, 772. 
See also Larynx, paralysis of, bilateral 
abductor. 
unilateral, 774 
prognosis, 774 
symptoms, 774 
treatment, 774 
Abductors of vocal cords, spasm of, 644 
Abscess, circumtonsillar, 482 

in acute glanders of pharynx, 598 
in empyema of antrum of Highmore, 372 
in nasal glanders, 175 

of brain complicating confined suppuration 
of frontal sinus, 408, 409 
suppurating ethmoiditis, 390 
of faucial tonsil, chronic, 511 
treatment, 511 
encysted, 511 
of septum, 335 
acute, 105, 335 
diagnosis, 336 
etiology, 335 

mucous membrane in, 336 
pain in, 336 
pathology, 336 
prognosis, 336 
swelling in, 336 
symptoms, 336 
treatment, 337 
chronic, 337 

treatment, 337 
deformity from, Roe's operation for, 341 
of soft palate, 447 
of uvula, 447 

orbital, complicating suppurating ethmoidi- 
tis, 390 
in empyema of antrum of Highmore, 373 
secondary to disease of accessory sinuses, 
351 
peritonsillar, 482. See also Abscess, ton- 
sillar. 
retropharyngeal, 602. See also Retro- 
pharyngeal abscess. 
subperiosteal, complicating confined sup- 
puration of frontal sinus, 408 
tonsillar, 482 

adhesion between tonsil and anterior and 

posterior palatine arches in, 484 
and lockjaw, resemblance, 483 
as cause of hypertrophic tonsillitis, 488 
bacteria as cause, 482 
coagulation-necrosis in, 483 
complications, 484 
diagnosis, 484 
edema in, 482, 483 
etiology, 482 
fluctuation in, 484 
glandular enlargement in, 482 
in infectious diseases, 482, 484 
involvement of carotid artery from, 484 
occlusion of Eustachian tube from, 484 
odor in, 483 
pain in, 483 
pathology, 482 
prognosis, 484 



Abscess, tonsillar, pus in, 483 
rupture in, 483 
synonyms, 482 

thickening of tonsillar structure in, 484 
thrombosis of jugular veins from, 484 
treatment, 485 
ulceration in, 483 
watery infiltration in, 482 
Abscess-formation in cryptic tonsillitis, 475 
Accessory cavities complicated in simple 
chronic rhinitis, 109 
in atrophic rhinitis due to pre-existing 

lesion, 135 
involvement of, in epidemic influenza, 88 
sinuses, diseases of, 348. See also Sinuses, 
accessory. 
in atrophic rhinitis secondary to lesion 

elsewhere, 128 
lesions of, nasal lesions from, 51 
Acid-applicator, MacCoy's, 709 
Acne, neurosis, reflex nasal, 214 

rose, 214 
Acoustics, 736 

of mouth, relation to voice, 738 
Actinic rays, condition simulating hyperes- 

thetic rhinitis due to, 198 
Actinomyces, 67 

Actinomycosis as cause of chondritis of lar- 
ynx, 669 
nasal, 179 

of antrum of Highmore, 379 
of ethmoidal sinuses, 393 
of faucial tonsil, 512 
of mucous membrane, 67 
of nasopharynx, 600. See also Pharynx, 

actinomycosis of. 
of pharynx, 600. See also Pharynx, actino- 
mycosis of. 
of tonsil, 600. See also Pharynx, actino- 
mycosis of. 
Adams' forceps, 343 

Adductor paralysis, laryngeal, bilateral, 775 
central, 774 
unilateral, 775 
Adenocarcinoma of respiratory tract, 286 
Adenoid cough, 634 

vegetations, 457 
Adenoiditis, chronic, 425 
Adenoids as cause of glottic spasm, 209 
of laryngeal spasm, 209 
of spasmodic croup, 209 
Adenoma of anterior nares, 238 
of fauces, 239 
of larynx, 240 

developing into malignancy, 240 
of nasopharynx, 238 
of respiratory tract, 238 

and fibroma, differentiation, 240 
diagnosis, 240 

differential, 240 
etiologv, 239 
pathology, 239 
symptoms, 239 
treatment, 240 
Adenotome, AlcAuliffe's, 470 

Schultz's, Richards' modification, 469 

805 






806 



INDEX. 



Adenotomy, 465 

spasmodic torticollis after, 470 
Adherent tonsil, 491 
Adhesions of soft palate and uvula, 450 

to pharvnx, closure of nasopharynx 
from, 450 
Adjustable chair, 34 
Adrenalin chlorid as tonsil styptic, 498 
Age for defects of speech, 751 

for operating in septal deformities, 327 
in acute nasopharyngitis, 422 
in chronic nasopharyngitis, 426 
in cough, 632 

in diagnosis of surgical tonsil, 493 
in emphysema of antrum of Highmore 380 
in follicular pharyngitis, 566 
in hypertrophic tonsillitis, 487 
in keratosis of pharynx, 608 
in perforation of septum, 333 
in sarcoma of larynx, 284 
in ulceration of septum, 329 
Agger nasi, 19 

Air pressure, negative, in accessory sinus dis- 
ease, 378 
Alse, nasal, collapse of, 327 

treatment, 327 
Alalia, 749 

Albuminuria in diphtheria, 534 
Alcohol in confined suppuration of antrum of 
Highmore, 370 
injection of, in dysphagia of laryngeal tuber- 
culosis, 712 
Alcoholism as cause of varices of lingual tonsil, 

517 
Alkalinity, excessive, of secretions as cause of 
rheumatism, 58 
effect of, on joints, 58 

on mucous membranes, 58 
Allen's nasal speculum, 36 

Septum-knife, 305 
Alligator biting-forceps, 319 

jaw-forceps, 121 
Allis' dissector, 506 
Alphabet, Makuen's physiologic, 757 
Altitude, high, as cause of cyanotic pharyngi- 
tis, 579 
of epistaxis, 219 
Alto voice, 734 

Alumnol solution as tonsil styptic, 498 
Amaurosis in diseases of accessory sinuses, 

419, 420 
Amblyopia in diseases of accessory sinuses, 

419, 420 
American catarrh, 425 
Ammonia, excess of, in secretion, effect of, on 

mucous membranes, 58 
Ammoniacal salts in saliva, 57 
Amygdalolith, 510 
Amyloid degeneration of mucous glands in 

keratosis of pharynx, 610 
Anarthria, 749 

Anemia, character of mucous membrane in, 51 
color of mucous membrane of accessory cavi- 
ties in, 23 
in pharyngeal tonsil, 463 
of larynx, 689. See also Larynx, anemia of. 
of pharynx, 614. See also Pharynx, anemia 
of. 
Anemic rhinitis, 84 
etiology, 84 
pathology, 84 
symptoms, 85 
treatment, 85 
Anesthesia, abdominal muscles in, 467 
chloroform and oxygen, 466 
competency of anesthetizer, 466 
cyanosis in, 467 
difficult respiration in, 467 
ether, 466 

• rectal method, 468 

foreign bodies drawn into respiratory 
tract during, 715 



Anesthesia in operation fo adenoids, 466 
in tonsillectomy, 495 
nitrous oxid and oxygen, 466 
of larynx, 760. See also Larynx, anes- 
thesia of. 
of pharynx, 615 
etiology, 615 
prognosis, 616 
treatment, 616 
of soft palate, 453 
Anesthetic leprosy, 177 
pathology, 177 
prognosis, 179 
Aneurysm as cause of cough, 633 

pharyngeal, 614 
Angina, catarrhal, acute, 472 
croupous, benign, 605 
diphtheritica, 530 
Ludovici, 558 
Ludwig's, 558 

synonyms, 558 
membranosa, 530 
rheumatic, 580 
stridulous, 649 
ulcerosa benigna, 559 
bacteria in, 560 
pain in, 559 
Vincent's, 558 

and diphtheria, differentiation, 559 
and ulcerative stomatitis, relation, 559 
bacteria in, 559 
symptoms, 559 
varieties, 559 
Angiofibromyxoma, nasal, 258 
Angioma of antrum of Highmore, 383 
of fauces, 242 

treatment, 242 
of larynx, 243 
« treatment, 243 
of nasal passage, 240 
color, 241 
diagnosis, 241 
hemorrhage, in, 241 
nasal obstruction in, 241 
pathology, 241 
prognosis, 242 
symptoms, 241 
treatment, 242 
of pharynx, 242 
of respiratory tract, 240 
of septum, 347 
of tonsil, 243 
of uvula, 242 
Angiomyxoma of septum, 347 
Angioneurotic edema as cause of cough, 633 
of larynx, 688 
of pharynx, 585 
treatment, 586 
edematous laryngitis, 656 ' 
Anorexia in secondary stage of acquired nasal 

syphilis, 150 
Anosmia, 192 
essential, 192 
intracranial, 192 
prognosis, 193 
treatment, 193 
Antitoxic serum in diphtheria, 541 
dose, 543 

early use, 543, 544 
Antrum, infections of, vaccine therapy in, 95 
of Highmore, 21, 22, 358 
actinomycosis of, 379 
anatomy, 358 
and teeth, relation, 358 
angioma, 383 
carcinoma, 383 
catarrhal inflammation, 359 
acute, 359 

closure of ostium maxillare as 

cause, 359 
diagnosis, 360 
edema of nasal mucosa in, 360 



INDEX. 



807 



Antrum of Highmore, catarrhal inflammation, 
acute, etiology, 359 
pain in, 360 
prognosis, 360 
symptoms, 360 
treatment, 360 
chronic, 361 
diagnosis, 363 
discharge in, 362 
etiology, 361 
pain in, 363 
prognosis, 363 
swelling in, 362 
symptoms, 362 
treatment, 363 
confined suppuration of, 368. See also 
Suppuration, confined, of antrum of 
Highmore. 
cvstic degeneration, 384 
cysts, 384 

dentigerous cysts, 384 
diseases of, 358 

transillumination in, 370 
emphysema of, 379. See also Emphy- 
sema of antrum of Highmore. 
empyema of, 364. See also Empyema 

of antrum of Highmore. 
enchondroma of, 383 
fibroma of, 383 
floor of, 358 
foreign bodies in, 381 
animate, 381 
diagnosis, 381 
prognosis, 381 
symptoms, 381 
treatment, 381 
inanimate, 381 
diagnosis, 381 
symptoms, 381 
treatment, 381 
glanders of, 379 
hydrops of, 361, 368 

and mucocele, symptoms alike, 382 
in acute infectious diseases, 379 
intranasal opening into, Mikulicz's 

method, 374 
mucocele of, 362, 382 

and hydrops antri, symptoms alike, 382 
diagnosis, 382 
pain in, 382 
pathology, 382 
pressure-symptoms, 382 
prognosis, 383 
« symptoms, 382 
thinning of walls in, 382 
treatment, 383 
myxoma of, 383 
opening of, 359 
osteoma of, 383 
ozena of, 364. See also Ozena of antrum 

of Highmore. 
pent-up pus in, 368 
treatment, 373 
phlegmonous inflammation, 384 
retention-cysts of, 384 
sarcoma of, 383 
syphilis of, 379 
transillumination of, 370 

through mouth, 371 
tuberculosis of, 379 
tumors, 383 
diagnosis, 384 
treatment, 384 
perforator, Douglas', 374 
Aphasia, 748 
Aphonia, 748 
functional, 766 
hysterical, 763 

and spastic dyspnea, 765 
definition, 763 
diagnosis, 763 
treatment, 765 



Aphonia in neuroses, reflex nasal, 209 
Aphthongia, 748, 752 
Aphthous sore throat, 605 
Applicator, nasal, 47 
Aprosexia, 748 

neurosis, reflex nasal, 214 
Arteries of nasal cavities, 24 
of nasopharynx, 27 
of nose, 285 

pulsating, of pharynx, 613 
Artery, carotid, involvement of, from tonsillar 
abscess, 484 
lateralis nasi, 290 
nasal, of septum, 290 
sphenopalatine, anatomy of, 24 
Articular rheumatism, acute, acute simple 

rhinitis in, 83 
Artificial larynx after laryngectomy, 803 
Arytenoid cartilage, chondritis of, 671 

symptoms, 674 
Arytenoids, club-shaped, 706 

paralysis of, 774 
Asch's knife, modified, 111 

operation as modified by Thorner for 
deflection of septum. 313 
Asphyxia in diphtheria, treatment, 545 
Aspirating apparatus, Thepsco, 374 
Aspirator, Jackson's, for esophagoscopes, 719 
Asthenopia in diseases of accessory sinuses, 

420 
Asthma associated with chronic hyperplastic 
ethmoiditis, 386 
cough in, 633, 634 

cyanotic rhinitis associated with, 144 
from nasal polypus, 259 
hay, 194 

in elongation of uvula, 445 
in follicular pharyngitis, 570 
in hyperplastic rhinitis, 121 
Miller's, 644 

predisposing to simple acute rhinitis, 75 
rachiticum, 644 
reflex nasal, 209 

after injuries to nose, 210 
classifications of, 211 
etiology, 209. 210 
exciting, 210 
toxic, 210 
hay fever associated with, 210 
hyperplasia of nasal mucous mem- 
brane in, 211 
irritating vapors as cause of, 210 
nasal obstruction as cause of, 210 
nervous system in, 211 
season predisposing to, 210 
sensitive areas of mucous membrane 

in, 211 
temperature in, 211 
treatment, 212 

vasomotor variety, etiology, 210 
thymic, 210, 645 
Asthmatic symptoms in hay fever, 201, 205 
Atmosphere as cause of chronic pharyngitis, 

561 
Atomizer, Bergson's, Llewellyn's modifica- 
tion of, 46 
Atomizers, 45, 46 
caution in using, 46 
straight-tube, 45 
Atresia, congenital, of pharynx, 519 
Atrophic bacillus, 130 
catarrh, 125 
endorhinitis, 125 
laryngitis, 685 
nasal catarrh, 125 
nasopharyngitis, 437. See also Naso- 

pharyngitis, atrophic. 
pharyngitis, 573. See also Pharyngitis, 

atrophic. 
rhinitis, 108, 125. See also Rhinitis, 
atrophic. 
Atrophy of faucial tonsil, 511 



808 



INDEX. 



Atrophy of mucous membrane in atrophic 
rhinitis secondary to lesion elsewhere, 137 

of turbinates in atrophic rhinitis, 128 
Aural complications in simple chronic rhinitis, 
109 

diphtheria, treatment, 545 
Automobile predisposing to taking cold, 74 
Autoscopy, 626 

Kirstein's method, 626 
Autumnal catarrh, 194 



Bacillus, atrophic, 130 
fcetidus, 70 
Klebs-Loffler, 70 
leprae, 68, 177 
mallei, 67, 174 

as cause of glanders of pharynx, 597 
mucosus ozense, 130 
of diphtheria, 70, 531 
as aid to diagnosis, 536 
on uvula, 448 
of glanders, 174 
of Koch, 166 
of pseudodiphtheria, 70 
of rhinoscleroma, 180 
Pfeiffer's, in epidemic influenza, 87 
rhinoscleromatis, 68 
segmentosis, 71 

in production of cold, 71 
of otitis media, 71 
tubercle, 67, 70, 166 

as cause of tuberculosis of larynx, 703 
in nasal lupus, 171 
von Hoffman's, 70 
in diphtheria, 532 
Backward children, speech defects in, 750 
Bacteria as cause of herpetic tonsillitis, 481 
of membranous laryngitis, 661 
of tonsillar abscess, 483 
faucial tonsil as nidus for development of, 

490 
in acute glanders of pharynx, 598 
in angina ulcerosa benigna, 560 
in atrophic pharyngitis, 575 

rhinitis, 130 
in chronic epipharyngeal periadenitis, 434 
in diphtheria, 532 
in infective pharyngitis, 527 
in keratosis of pharynx, 612 
in membranous tonsillitis, 486 
in pharyngomycosis, 607 
in purulent rhinitis, 140 
in simple acute rhinitis, 75 
in Vincent's angina, 559 
influencing ulceration of septum, 329 
lactic-acid, in atrophic rhinitis due to pre- 
existing local lesion, 136 
nasal, 71 

relation of, to disease, 68 
number ingested, 93 
of uvula, 448 
Bacteriotherapy, lactic, in pharyngeal affec- 
tions, 528 
Balbuties, 749 

Ballenger-Hajek's elevator, 308 
Ballenger's operation for septal deviation, 

319 
Baritone voice, 734 
Barking cough, spasmodic, 633 
Basement membrane of mucous membrane, 
60 
connective tissue in, 59 
varying thickness of, 60 
Bass voice, 734 

Bastin's definition of word-blindness, 753 
Bed-sore, laryngeal, 669 
Bergson's atomizer, Llewellyn's modification 

of, 46 
Bermingham nasal douche, 47 
Bifid uvula, 443 
cough in, 444 



Bifid uvula, treatment, 444 
Biliary material in saliva, 56 
Bivalve nasal speculum, 37 
Black tongue involving pharynx, 555 
Bleeders, tonsillectomy in, 499 
Bleeding from nose, 217. See also Epistaxis. 
polypus, 258 
of septum, 347 
Blennorrhea, acute nasal, 74 

chronic, 107 
Blepharospasm in diseases of accessory sinuses, 

419, 420 
Blind spot, enlargement of, in diseases of ac- 
cessory sinuses, 419 
Blindness in diseases of accessory sinuses, 419, 
420 
word-, 753 

from disease of accessory sinuses, 351 
Blood, opsonic strength of, 94 

opsonins in, 94 
Blood-changes in nasal obstruction, 53 
Blood-cysts, 288 
of septum, 347 
treatment, 347 
Blood-supply, alterations in, as cause of 
chronic pharyngitis, 560 
in nasal polypus, 259 

tuberculosis, 167 
of nasal cavities, 24 
Blood-vessels in carcinoma of nasal passage, 
268 
in tertiary form of acquired nasal syphilis, 
149 
Bodies, swollen, 24 
Bone transplantation operation, Carter's, for 

nasal deformity, 345 
Bone-cysts of accessory sinuses, 381 
Bone-forceps, Milbury's, 111 

septal, 308 
Bones and cartilages of septum, fig. 3 
turbinated, 19. See also Turbinate. 
Bony necrosis from diseases of accessory 

sinuses, 351 
Bowman, glands of, 24 

Brain, abscess of, complicating confined sup- 
puration of frontal sinus, 408, 409 
suppurating ethmoiditis, 390 
involvement of, in tertiary syphilis of 
pharynx, 596 
Brassy cough, 633 

Brawley's aspirating apparatus, 379 
Breathing, mouth-, 52. See also Mouth- 
breathing. 
nasal, importance of, 52, 114 
in early childhood, 297 
in relation to hearing, 114 
in hyperplastic rhinitis, 118 
results of failure, 52 
noisy, in hereditary nasal syphilis, 163 
Bronchi, diseases of, from foreign bodies, 716 
Bronchial cough, 634 

glands, enlarged, as cause of cough, 633 

of laryngismus stridulus, 645 
tubes, 18 
Bronchitis, capillary, and membranous laryn- 
gitis, differentiation, 665 
in hyperplastic rhinitis, 121 
Broncholith as cause of cough, 633 
Bronchoscope for adults, Jackson's, 716 

Jackson's, 716 
Bronchoscopic battery, double, 717 
Bronchoscopy, 716 

for foreign bodies, 716 
instruments for, 717 
Jackson's method, 718 
lower, Jackson's method, 727 
superior, technic of, 718 
Brown's operation for septal deviation, 325 
Brun's epiglottis pincet, 653 
Bryan's ethmoid curet, 391 

operation for confined suppuration of frontal 
sinus, 409 



INDEX. 



809 



Bubo, indolent, in acquired nasal syphilis, 150 
Buccal cavities an important factor in develop- 
ment of speech, 747 
tonsil, 513 
Bulbar paralysis, acute, of soft palate, 454 
apoplectiform, of soft palate, 454 
chronic, of soft palate, 454 
progressive, of pharynx, 618 
symptoms, 618 
Bursa, Luschka's, 457 
pharyngeal, 26 

in etiologv of chronic nasopharyngitis, 

426 
suppuration of, empyema of sphenoidal 
sinus and, differentiation, 397 
Bursitis, nasopharyngeal, chronic, 432 



Cachexia in cancer of larynx, 276 
in sarcoma of larynx, 285 
of pharynx, 282 
Calcined magnesia in papilloma of larvnx in 

children, 238 
Calculi, nasal, 224. See also Rhinoliths. 
Canal, lacrimal, occlusion of, in hyperplastic 

rhinitis, 119 
Capillary bronchitis and membranous laryn- 
gitis, differentiation, 665 
Carcinoma of antrum of Highmore, 383 
of ethmoidal sinuses, 393 
of larynx, 273 

advisability of operation, 800 

and chondroma, differentiation, 245 

and chronic larvngitis, differentiation, 

682 
and syphilis, differentiation, 700 
and tuberculosis, differentiation, 707 
assumption as to malignancy, 273 
cachexia in, 276 
diagnosis, 277 
dysphagia in, 276 
dyspnea in, 276 
glandular involvement in, 276 
hemorrhage in, 276 
odor in, 276 
pain in, 276 
pathology, 275 
prognosis, 277 
Rontgen rays in, 278 
secretion in, 276 
sex in, 275 
surgery of, 794 
symptoms, 276 
treatment, 277 
ulceration in, 276 
voice in, 276 
of nasal passage, 267 

blood-vessels in, 268 

Cohnheim inclusion theory of cause, 

267 
diagnosis, 268 
discharge in, 268 
epithelial cells in, 268 
etiology, 267 
eye-symptoms in, 268 
glandular involvement in, 268 
hemorrhage in, 268 
irritation as cause, 267 
pain in, 268 
pathology, 267 
prognosis, 269 
symptoms, 268 
treatment, 269 
of nasopharynx, 269 
diagnosis, 269 
pain in, 269 
prognosis, 269 
symptoms, 269 
treatment, 269 
of pharynx, 271 

and fibroma, differentiation, 272 
and syphilis, differentiation, 272 



Carcinoma of pharynx, diagnosis. 272 
differential, 272 
involvement of lymphatics in, 272 
pain in, 272 
prognosis, 272 
symptoms, 272 
treatment, 272 
voice in, 272 
of respiratory tract, 267 
of soft palate, 270 
diagnosis, 271 
dyspnea in, 271 
irritation as cause, 270 
loss of free movement of palate in, 271 
pain in, 271 
prognosis, 271 
recurrence, 270, 271 
spread, 270 

by lymphatics, 270 
symptoms, 271 
treatment, 271 
ulceration in, 271 
voice in, 271 
of sphenoidal sinuses, 398 
of tonsil, 272 

and sarcoma, differentiation, 284 
treatment, 273 
of uvula, 270 
Cardiac cough, 634 

lesions as cause of edematous laryngitis, 657 
Caries in acute purulent empyema of frontal 
sinus, 404 
in confined suppuration of frontal sinus, 408 
in empyema of antrum of Highmore, 372 
in tertiary period of acquired nasal svphilis, 

149 
of cervical vertebra?, retropharyngeal ab- 
scess associated with, 603 
of septum, 328 

of vertebrae as cause of laryngismus stridu- 
lus, 645 
Carotid artery, involvement of, from tonsillar 

abscess, 483 
Carter's bone transplantation operation for 
nasal deformity, 345 
bridge-splint operation for correction of 

nasal deformities, 341 
chisel, 343 
chisel-forceps, 343 
nasal splint, 342 
Cartilage and bones of septum, fig. 3 
arytenoid, chondritis of, 671 

symptoms, 674 
columnar, 295 
cricoid, chondritis of, 671 

symptoms, 674 
in tertiary period of acquired nasal syphilis, 

149 
lateral, of nose, 19 
nasal, depression of, 338 
etiology, 338 
Roe's operation for, 341 
treatment, 339 
White's operation for, 339 
of septum, 289 
lower lateral, 290 
upper lateral, 289 
order of involvement, in chondritis of 

larynx, 671 
sesamoid, 290 
thyroid, chondritis of, 671 
symptoms, 674 
splitting of, 796 
Cartilage-formation in rhinoscleroma, 181 
Cartilagines minores, 290 
Cartilaginous framework of septum, 289 
Caseous rhinitis, 86 
synonyms, 86 
treatment, 87 
tonsillitis, 509. See also Tonsillitis, caseous. 
Casselberry's operation for septal deviation, 
323 



810 



INDEX. 



Catarrh, acute nasal, 74 
American, 425 
as symptom, 51 
atrophic, 125 
autumnal, 194 
common sporadic, 74 
definition, 51 
dry, 64, 125 
nasal, 125 
fetid, 125 

nasal, atrophic, 125 
chronic, 107 
dry, 64, 127 
hypertrophic, 116 
purulent, 140 
simple chronic, 107 
of larynx, acute, 634 

chronic, 677 
of nasopharynx, acute, 421 

chronic, 425 
pollen, 194 
postnasal, acute, 421 
chronic, 425 

from ulceration of uvula, 448 
retronasal, acute, 421 

chronic, 425 
rose, 194 

runs into consumption, 52 
simple, 74 
specific, 145 
sporadic, common, 74 
summer, 194 
Catarrhal angina, acute, 472 

conditions after infectious diseases, 73 

predisposing to hyperesthetic rhinitis, 199 
croup, 649 

diathesis, slit-like nostril in, 52 
inflammation, acute, of frontal sinus, 399. 
See also Frontal sinus, catarrhal inflam- 
mation of, acute. 
chronic, of frontal sinus, 401. See also 
Frontal sinus, catarrhal inflammation 
of, chronic. 
of antrum of Highmore, 359. See also 
Antrum of Highmore, catarrhal inflam- 
mation of. 
of ethmoidal sinuses, 385 
diagnosis, 385 
symptoms, 385 
treatment, 386 
of mucous membrane, 62 
acute, 62 
chronic, 63 
of sphenoidal sinuses, 394. See also 

Sphenoidal sinuses, catarrhal inflam- 
mation. 
laryngitis, 649 

acute, 634. See also Laryngitis, catarrhal, 
acute. 
pharyngitis, acute, 521 

pneumonia after spasmodic laryngitis, 651 
rhinitis, 74 
tonsillitis, acute, 472 
ulcers, 185 

in acute nasopharyngitis, 423 
treatment, 185 
Catarrhus sestivus, 194 

longus, 107 
Cavernous sinus, suppuration of, from empy- 
ema of sphenoidal sinus, 397 
thrombosis of, eye signs, 420 

from suppurating ethmoiditis, 390, 391 
Cell-nutrition, chemistry of, 54 
Cells, chalice-, 24 

embryonic, in purulent rhinitis, 140 
epithelial, in cancer of nasal passage, 268 
ethmoidal, anatomy of, 21 

diseases of, 384. See also Ethmoidal 
sinuses. 
goblet-, 24 

in keratosis of pharynx, 610 
in nasal leprosy, 178 



Cells in nasal lupus, 171 
tuberculosis, 167 
in rhinoscleroma, 180 
olfactorial, of Schultze, 24 
Cellulitis, acute, of larynx, 656 
of neck, 558 

orbital, from disease of accessory sinuses, 
351 
Cerebral croup, 644 
Cerumen, impacted, cough from, 212 
Cervical glands, enlarged tonsil and, relation- 
ship, 492 
vertebra?, caries of, retropharyngeal abscess 
associated with, 603 
Chair and stool for office work, 34 
Chalice-cells, 24 
Chancre, nasal, 188 
Chatelier's submucous resection for deviation 

of septum, 299 
Chemic ulcers, nasal, 187 

treatment, 188 
Chemistry, altered, of saliva, 53 

faultv, of secretion, predisposing to taking 

cold, 73 
of body and cell-nutrition, 54 
of saliva in hyperesthetic rhinitis, 195 
of secretion, altered, as cause of hyper- 
esthetic rhinitis, 195 
Chicken-pox, pharynx in, 558 

treatment, 558 
Child-crowing, 644 

Chilling as cause of acute simple rhinitis, 75 
Chisel, Carter's, 343 
Lewis septum, 308 
Chisel-forceps, Carter's, 343 
Chloroform and oxygen anesthesia, 466 
Choanse, 26 

Choking in elongation of uvula, 445 
in pharyngeal tonsil, 463 
in suppurative laryngitis, 655 
in tuberculosis of larynx, 705 
Cholesteatoma of faucial tonsil, 509 
Cholesteatomatous rhinitis, 86 
Chondritis as cause of cough, 632 
of edematous laryngitis, 657 
of arytenoid cartilage, 671 

symptoms, 674 
of cricoid cartilage, 671 

symptoms, 674 
of epiglottis, 671 

of larynx, 668. See also Larynx, chon- 
dritis of. 
of thyroid cartilage, 671 

symptoms, 674 
of tracheal rings, 671 
Chondroma of larynx, 245. See also Larynx, 
chondroma of. 
of nasal passage, 243 

and fibroma, differentiation, 244 
and osteoma, differentiation, 244 
diagnosis, 244 
hemorrhage in, 244 
nasal obstruction in, 244 
ossification in, 244 
pain in, 244 
prognosis, 244 
symptoms, 244 
treatment, 244 
of nasopharynx, 244 
of respiratory organs, 243 
Chorditis nodosa, 691 
tuberosa, 691 
vocalis inferior, 689 
Chorea, cough in, 633 

in hyperplastic rhinitis, 121 
neurosis, reflex nasal, 213 
of larynx, 766 
synonym, 766 
treatment, 767 
Cicatricial tissue in nasal leprosy, 179 
Cicatrization in lupus of pharynx, 591 
in tertiary syphilis of larynx, 699 



INDEX. 



811 



Cicatrization in tuberculosis of pharynx, 587 
Cicatrix, fibrous, in nasal lupus, 172 

tuberculosis, 167 
Circulation, venous, interference with, as 

cause of hypertrophic tonsillitis, 588 
Circumtonsillar abscess, 482 
Cirrhotic rhinitis, 125 
Clamp, Pierce's, 499 
Clergyman's sore throat, 560, 566, 684 
Climate as cause of acute nasopharyngitis, 422 
simple rhinitis, 75 
of chronic nasopharyngitis, 427 
of congestion of mucous membrane, 114 
of enlargement of pharyngeal tonsil, 459 
of follicular pharyngitis, 567 
of hyperplastic rhinitis, 117 
of hypertrophy of faucial tonsil, 487 
effect of, on mucous membrane of pharynx 
or larynx, 580 
on voice, 732, 733 
Clonic spasm of pharynx, 617 
Closure of nasopharynx by adhesion of soft 

palate to pharynx, 450 
Clothing predisposing to acute simple rhinitis, 

75 
Club-shaped arytenoids, 706 
Coagulation-neurosis in membranous tonsil- 
litis, 486 
in tonsillar abscess, 483 
of mucous membrane, 65 
Coakley transilluminator, 372 
Cocain in examination of throat, 41 
Cocci, pyogenic, 71 
Cohen's forceps, 441 

sign in foreign bodies in larynx, 729 
tracheal tube, 788 
Cohnheim inclusion-theory as to cause of 

cancer of nasal passage, 267 
Cold, 74 

Bacillus segmentosus in production of, 71 
in head, 74 

symptoms, 77 
June, 194 
peach, 194 
rose, 194 
taking, 72 

automobile predisposing to, 74 

causes of, 73 

contagious diseases predisposing to, 73 

digestive disturbances predisposing to, 73 

draughts, predisposing to, 73 

dust predisposing to, 74 

fatigue predisposing to, 73 

faulty chemistry of secretion predisposing 

to, 73 
in intumescent rhinitis, 115 
infectious diseases predisposing to, 73 
lithemic condition in, 73 
nasal congestion predisposing to, 74 
irregularities predisposing to, 73 
obstruction predisposing to, 73 
occupation predisposing to, 74 
poor ventilation predisposing to, 73 
seasons predisposing to, 73 
sensitive skin predisposing to, 73 

mucous membrane predisposing to, 73 
smoke predisposing to, 74 
sudden changes of temperature predispos- 
ing to, 73 
susceptibility to, 72 
treatment of, 74 
vapors predispsing to, 74 
Collapse of nasal alse, 327 

treatment, 327 
Colles' law of immunity in nasal syphilis, 146 
Color of angioma of nasal passage, 241 
of anterior nasal cavities, 43 
of mucous membrane in acute pharyngitis, 
522 
in hyperplastic rhinitis, 118 
of accessory sinuses, 23 
in anemia, 23 



Color of mucous membrane of accessory 
sinuses in plethora. 23 
of anterior nasal cavities, 23 
of nasal polypus, 257 
Columnar cartilage, 295 
Concha Santoriniana, 19 
Conchotome, Milbury's, 111 
Concretions, nasal, 224 
Condyloma as symptom of syphilis of larynx, 

697 
Congenital insufficiency of palate, 449 

treatment, 450 
Congestion, cyanotic, chronic pharyngitis 
from, 560 
in tissues remote to organ in cyanotic 
rhinitis, 144' 
nasal, predisposing to taking cold, 74 
of mucous membrane, climate as cause of, 
114 
exhaustion as cause of, 114, 115 
gastric diseases as cause of, 114 
lesions of respiratory tract as cause 

of, 114 
sexual excitement as cause of, 115 
of viscera causing alteration in mucous 
membrane, 51 
Connective-tissue elements of submucosa, 
increase of, in hyperplastic rhinitis, 
116 
of tonsil, increase of, in rheumatic ton- 
sillitis, 479 
in hypertrophic tonsillitis, 488 
layer of basement membrane, 59 
papilla? in keratosis of pharynx, 609 
tumors, embryonic, 278 
Constipation, chronic, congested mucous 
membrane in, 51 
in cryptic tonsillitis, 476 
Constitutional conditions favoring epistaxis, 
218 
debility in simple chronic rhinitis, 108 
diseases, acute laryngitis in, 639 

as cause of chronic pharyngitis, 561 
increased exudate from mucous mem- 
brane in, 51 
simple acute rhinitis, in, 82 
ozena, 125 
symptoms in nasal hydrorrhea, 143 

of follicular pharyngitis, 570 
treatment of late secondary nasal syphilis, 
153 
Consumption, catarrh runs into, 52 
of larynx, 703 
of pharynx, 586 
of throat, 703 
Contagious diseases predisposing to taking 

cold, 73 
Contralto voice, 734 
Convulsions in spasm of larynx in children, 

647 
Convulsive neurosis of nasopharynx, 442 
Coolidge's cotton holders, 719 
Corpora cavernosa, turbinated, 24 
Corwin's tonsil hemostat, 499 
Coryza. acute, 74' 



chronic, 107 

fetid, 125 

idiosyncratic, 194 

in epidemic influenza, 87 

in secondary stage of acquired nasal 
syphilis, 150 
pathology, 147 

vasomotoria periodica, 194 
Cotton, waste, receptacle for, 38 
Cotton-holders, Coolidge's, 719 
Cotton-reservoir and waste-box, 38 
Cough, 632 

adenoid, 634 

at puberty, 633 

barking, spasmodic, 633 

brassy, 633 



812 



INDEX. 



Cough, bronchial, 634 
cardiac, 634 

character of secretion expectorated, 633 
croupy, 633 
definition, 632 
ear, 634 
etiology, 632 

age, 632 

aneurysm, 633 

angioneurotic edema, 633 

broncholiths, 633 

chondritis, 634 

edema, 633 

elongation of uvula, 632 

enlarged bronchial glands, 633 
tonsils, 632 

foreign bodies, 633, 716 

drawn into respiratory tract during 
anesthesia, 715 

hardened wax in the ear, 632 

impacted cerumen, 212 

mechanical irritation of nasal mucous 
membrane, 632 

nasal growths, 633 

paralysis of larynx, 633 

perichondritis, 632 

trauma of nose, 633 

tumors of larynx, 633 
hacking, dry, 633 
hepatic, 634 
hysterical, 633 

in acquired stenosis of larynx, 630 
in acute catarrhal laryngitis, 636 

laryngitis in children, 643 

pharyngitis, 523 

uvulitis, 447 
in asthma, 633, 634 
in atrophic pharyngitis, 575 

rhinitis due to pre-existing lesion, 133 i 
in bifid uvula, 444 
in chorea, 633 
in chronic nasopharyngitis, 429 

pharyngitis, 564 

purulent inflammation of antrum of 
Highmore, 368 
in cryptic tonsillitis, 475 
in cyanotic pharyngitis, 579 
in dry laryngitis, 686 
in edematous laryngitis, 659 
in elongation of uvula, 444 
in follicular larvngitis, 684 

pharyngitis, 566, 570 
in foreign bodies in larynx, 728 
in glandular pharyngitis lateralis, 552 
in hemorrhagic laryngitis, 667 
in hyperplastic rhinitis, 119 
in hypertrophic tonsillitis, 490 
in keratosis of pharynx, 612 
in laryngeal hemorrhage, 713 
in membranous laryngitis, 663 
in nasal hydrorrhea, 143 
in nervous diseases, 633 
in pharyngeal tonsil, 462 
in pharyngomycosis, 607 
in preglottic tonsillitis, 514 
in retropharyngeal abscess, 603 
in sarcoma of larynx, 285 
in scleroma of larynx, 689 
in secondary syphilis of pharynx, 594 
in spasmodic laryngitis, 651 
in suppurative laryngitis, 655 
in syphilis of larynx, 695 
in tuberculosis of larynx, 705 

of pharvnx, 587, 588 
laryngeal, 633, 634 
nasal, 208, 634 
nervous, 634, 759 
night-, 633 
of fatigue, 634 
paroxysmal, 633 
pleuritic, 634 
rattling, loose, 633 



Cough, renal, 634 
resonant, deep, 633 
rum, 560 
spots, 634 
stomach, 634 
uterine, 634 
varieties of, 633 
Coulter's inhaler, 49 
Cranial cavity, infection of, from suppurating 

ethmoiditis, 390 
Crapon on laryngofissure in tuberculosis of 

larynx, 710 
Cri de canard in retropharyngeal abscess, 

603 
Crico-arytenoid muscle, paralysis of, in laryn- 
gismus stridulus, 645 
Crico-arytenoids, lateral, paralysis of, 775 
Cricoid cartilage, chondritis of, 671 

symptoms, 674 
Croup, catarrhal, 649 
cerebral, 644 
diphtheritic, 661 
false, 642, 644, 649 
fibrinous, 661 
membranous, 661 
idiopathic, 661 
mucous, 649 
pseudomembranous, 661 

and spasmodic laryngitis, differentiation, 
651 
spasmodic, 642, 644, 649 

adenoids as cause of, 209 
spurious, 634, 649 
true, 661 
Croupous angina, benign, 605 

inflammation of mucous membrane, 64 

laryngitis, 661 

membranous laryngitis, 661 

pharyngitis, 529. See also Pharyngitis, 

croupous. 
rhinitis, 97. See also Rhinitis, croupous. 
ulcers, nasal, 190 
Croupy cough, 633 

Crusts in atrophic rhinitis due to pre-exist- 
ing lesion, 132, 133 
in nasal lupus, 172 
Cruveilhier's submucous venous plexus, 242 
Cryptic tonsillitis, 471, 474. See also Ton- 
sillitis, cryptic. 
Crypts in caseous tonsillitis, 509 

tonsillar, 26 
Curet, Bryan's, 391 
Gottstein's, 469 
Kyle's, 469 
Mayer's, 589 
Curetment in tuberculosis of pharynx, 589 
Curets, Myles', 363 
Cyanosis in anesthesia, 467 

in suppurative laryngitis, 655 
Cyanotic congestion, chronic pharyngitis from, 
560 
in tissues remote to organ in cyanotic 

rhinitis, 144 
of larynx, 657 
laryngitis, 688. See also Laryngitis, cyan- 
otic. 
pharyngitis, 579. See also Pharyngitis, 

cyanotic. 
rhinitis, 144. See also Rhinitis, cyanotic. 
Cynanchea trachealis, 661 
Cystic degeneration of antrum of Highmore, 
384 
tumors of frontal sinus, 415 
Cystoma, 287, 288 
Cysts, blood-, 288 
of septum, 347 
treatment, 347 
bone-, of accessory sinuses, 383 
classification, 287 
dermoid, 287, 288 
treatment, 288 
of antrum of Highmore, 384 



INDEX. 



813 



Cysts of antrum of Highmore, dentigerous, 
384 
retention, 384 
of frontal sinus, 415 
of respiratory tract, 287 
retention, 287 

of antrum of Highmore, 384 
treatment, 287 
simple, 287 

treatment, 287 
Czerny's operation for sarcoma of tonsil, 284 



Deaf, teaching to hear, 750 
Deaf-mutism, treatment, 742, 743 
Deafness in hyperplastic rhinitis, 121 

in pharyngeal tonsil, 462, 463 
Deflection or deviation of septum, 294. See 

also Septum, deviation or deflection of. 
Deformities, facial, in hereditarv nasal syph- 
ilis, 164 
from abscess of septum, Roe's operation for, 

341 
in sarcoma of nose, 279 
nasal, external, correction of, 338 

Carter's bone transplantation opera- 
tion for, 345 
bridge-splint operation for, 341 
from nasal lupus, 172 
syphilis, 151 

paraffin injections in, lot 
Gersuny's method for correcting, 154 
paraffin injections for, 154 
of larynx, 628 
of pharynx, 519 
of septum, 293 
Degeneration, amyloid, of mucous glands in 
keratosis of pharynx, 610 
cystic, of antrum of Highmore, 384 
fibroid, areas of, in acquired tertiary nasal 

syphilis, 152 
fibrous, in chondritis of larynx, 675 
hyaline, in keratosis of pharynx, 611 
hydropic, in edematous laryngitis, 658 
in occupation-rhinitis, 103 
mucoid, and nasal polypus, differentiation, 
260 
Degenerative changes in mucocele of frontal 
sinus, 413 
in nasal lupus, 170 
Delavan's electrolysis needles, 242 
Delirium in empyema of sphenoidal sinus, 396 
Dennis's syringe, 709 
Dentigerous cvsts of antrum of Highmore, 

384 
Depression of nasal cartilages, 338 
etiology, 338 
treatment, 339 
White's operation for, 339 
Dermoid cysts, 287, 288 

treatment, 288 
Deviation or deflection of septum, 294. See 

also Septum, deviation or deflection of. 
Diabetes melhtus, acute simple rhinitis in, 

83 
Diabetic ulcers, nasal, 187 
Diet in diphtheria, 540 

Digestive disturbances as cause of chronic 
pharyngitis, 560 
in chronic pharyngitis, 564 
in hyperplastic rhinitis, 121 
predisposing to taking cold, 73 
Dilatation of pharynx, 520 
of pouches of larynx, 629 
of veins at base of tongue, 517 
Dilator, Mackenzie's, 631 
Sinexon's, 302 
Trousseau's, 791 
Whistler's, 629 
Diphtheria, 530 

acute simple rhinitis in, 83 
albuminuria in, 534 



Diphtheria and acute tonsillitis, differentia- 
tion, 536 
and membranous laryngitis, differentia- 
tion, 662, 664 
resemblance, 662 
and Vincent's angina, differentiation, 559 
bacillus of, 70, 531 

as aid to diagnosis, 536 
on uvula, 448 
bacteria in, 532 
bacteriology, 531, 532 
color of membrane, 535 
consistency of membrane, 535 
definition, 530 
diagnosis, 536 

bacillus as aid, 536 
dysphagia, 537 
lingual tonsil, 537 
method, 536 
nasopharynx, 537 
pain, 537 
tonsils, 537 
etiology, 530 
local, 531 
predisposing, 531 
specific, 531 
facial expression in, 534 
false membrane in, 532 
glandular involvement in, 534 
headache in, 533 
hematuria in, 534 
history, 530 

inspection of mouth in, 534 
lacunar, 535 
laryngeal, 661 

method of examining throat in, 537 
nasal, 102, 535 

and croupous rhinitis, differentiation, 99 
acute, 535 
chronic, 535 

diagnosis, differential, 536 
ulcers in, 190 
odor in, 534 
pain in, 533 
pathology, 532 
period of incubation, 533 
prognosis, 537 

based on bacteriological examination, 540 
on condition of heart, 538 
of kidney, 539 
of lungs, 539 
of pulse, 538 
on extension of membrane, 538 
on neuroses, 539 
on temperature, 538 
date and mode of death, 540 
pseudobacillus of, in infective pharvngitis, 

527 
pulse in, 534 

situation of membrane, 534 
symptoms, 533 
synonyms, 530 
temperature in, 534 
tongue in, 533 
treatment, 540 

antitoxic serum, 541 
dose, 543 
early use, 544 
complications, 545 
asphyxia, 545 
aural, 545 

laryngotracheal, 545 
ocular, 545 
paralysis, 545 
constitutional, 541 
dietetic, 540 

disinfection of sick-room, 547 
hygiene, 546 
immunity, 541 
injection, 542 
serum, 542 
syringe, 542 



814 



INDEX. 



Diphtheria, treatment, local remedies, 541 
Loffler's solution, 541 
prophylaxis, 546 
sequels, 545 
stimulants, 545 

urine in, 534 

voice in, 533 

vomiting in, 533 

von Hoffmann's bacillus in, 532 
Diphtheritic croup, 661 

inflammation of mucous membrane, 64 

membranous laryngitis, 661 

paralvsis of pharynx, 618 

rhinitis, 102 

chronic form, 102 
definition, 102 
svnonym, 102 
Diphtheritis, 530 
Diphtheroids, 71 
Diphthongia, 749 
Diplacusis, 749 

Diplococcus coryzae in simple acute rhinitis, 
75 

Loewenberg's ozena, 70 
Diplophonia, 749, 752 
Discrete tonsils, 457 
Dislocation of septum, 296 
Dissector, Allis', 506 
Diverticulum of pharynx, 520. See also 

Pharynx, diverticulum of. 
Divulsor, Pierce's, 485 
Dome of pharynx, 26 

Donelan on creosote and guaiacol in tuber- 
culosis of larynx, 711 
Donelan's syringe, 712 
Douche, Bermingham nasal, 47 

nasal, caution in using, 46 
Douglas' antrum perforator, 374 

operation for septal deviation, 322 
Dovle's method of finger enucleation of tonsil, 

507 
Drainage in acute simple rhinitis, 77 
Draughts predisposing to taking cold, 73 
Drawback phonation. 752 
Drill, Palmer's, 414 

Drugs as cause of acute simple rhinitis, 76 
Dry catarrh, 64, 125 

hacking cough, 633 

laryngitis, 685. See also Laryngitis, dry. 

nasal catarrh, 125 

pharyngitis, 573. See also Pharyngitis, 
atrophic. 
Duct, lacrimal, in atrophic rhinitis secondary 
to lesion elsewhere, 139 
• position of, 22, fig. 5 
Dust as cause of chronic pharyngitis, 561 

predisposing to taking cold, 74 
Dyslalia, 749 
Dysodia, 125 
Dysophresia, 192 

Dyspepsia as cause of chronic nasopharyn- 
gitis, 426 
Dyspeptic symptoms in atrophic rhinitis due 

to pre-existing lesion, 133 
Dysphagia in cancer of larynx, 276 

in diphtheria as aid in diagnosis, 537 

in syphilis of larynx, 696 

in tuberculosis of larynx, alcohol injection in, 
712 
Dysphonia clericorum, 566 

spastica, 767 
synonym, 767 
treatment, 767 
Dyspnea, expiratory, from pressure on trachea, 
210 

in acute uvulitis, 447 

in cancer of larynx, 276 
of soft palate, 271 

in edematous laryngitis, 658 

in membranous laryngitis, 663, 664 

in mucocele of larynx, 266 

in papilloma of larynx, 236 



Dyspnea in sarcoma of pharynx, 282 
in spasm of larynx, 648 

in children, 647 
in syphilis of larynx, 696 
in tuberculosis of larynx, 705 
spastic, and hysterical aphonia, 765 



Ear affections, neuroses, reflex nasal, 212 
cough, 634 

hardened wax in, as cause of cough, 632 
in chronic nasopharyngitis, 429 
middle, catarrhal affections of, associated 
with chronic hvperplastic ethmoiditis, 
386 
sclerosis of, in chronic epipharyngeal peri- 
adenitis, 433 
musical, 737, 739, 742 
neurosis of nasopharynx, 442 
Ear-symptoms in acute pharyngitis, 523 
in acute superficial tonsillitis, 472 
in cryptic tonsillitis, 476 
in empyema of sphenoidal sinus, 396 
in glandular pharyngitis lateralis, 552 
in hypertrophic tonsillitis, 490 
in lupus of pharynx, 591 
in syphilis of pharynx, 594 
Earache in pharyngeal tonsil, 463 
Echolalia, 746, 748 
Ecraseur, Gibb's, 243 
Ecthyma of pharynx, 604 
Eczematous ulcers, nasal, 185 

treatment, 186 
Edema, angioneurotic, as cause of cough, 633 
of pharynx, 585 
treatment, 586 
as cause of cough, 633 
glottidis, 656 
in acute pharyngitis, 522 
in sarcoma of pharynx, 282 
in tonsillar abscess, 482, 483 
in traumatic laryngitis, 653 
of eyelids from disease of accessory sinuses, 

351 
of glottis, 656 

and membranous larvngitis, differentia- 
tion, 664 
from urticaria of pharynx, 605 
in occupation-pharyngitis, 550 
of larynx and chronic laryngitis, differen- 
tiation, 681 
and membranous laryngitis, differentia- 
tion, 664 _ 
angioneurotic, 688 
chronic, 657, 661, 688 
treatment, 661 
of nasal mucosa in acute catarrhal inflam- 
mation of antrum of Highmore, 360 
of septum, 335 

treatment, 335 
of uvula, 446 
Edematous laryngitis, 656. See also Laryn- 
gitis, edematous. 
rhinitis, acute, 105 
etiology, 105 
treatment, 105 
chronic, 144. See also Rhinitis, cyanotic. 
Electric sterilizer, Lewis', 50 
Electrode for direct laryngoscopy, 711 
Mackenzie's laryngeal, 771 
Scheppegrell's, 711 
Electrolysis in hyperplastic rhinitis, 122 
Elephantiasis Grsecorum, 177 
Elevator, Ballenger-Hajek's, 308 

Freer's, 308 
Elongation of uvula, 444. See also Uvula, 

elongation of. 
Emboli, infected, as cause of chondritis of 

larynx, 669 
Embryonic cells in purulent rhinitis, 140 
connective-tissue tumors, 278 
epithelial tumors of respiratory tract, 267 



INDEX. 



815 



Emphysema of antrum of Highmore, 379 
age in, 380 
definition, 379 
diagnosis, 380 

escape of gas into nose, mistaken diag- 
nosis from, 380 
etiology, 380 
headache in, 380 
pressure-pain in, 380 
pressure-symptoms in, 380 
prognosis, 380 
symptoms, 380 
treatment, 380 
of face from injury of turbinate bone, 113 
of neck in foreign bodies in larynx, 729 
of soft palate, 449 

treatment, 449 
of tissues of neck in chondritis of larynx due 

to typhoid fever, 673 
of uvula, 449 
treatment, 449 
Empyema of antrum of Highmore, 364 
abscess in, 372 
caries in, 372 
complications, 372 
intracranial, 373 
in young, 366 
orbital abscess in, 373 
purulent, acute, 364 

diagnosis, 365 

discharge in, 365 

etiology, 364 

gastric disturbance in, 365 

pain in, 365 

pathology, 365 

prognosis, 366 

pus in, 365 

symptoms, 365 

systemic infection in, 365 

teeth as cause of, 365 

tenderness in, 365 
chronic, 366 

active form, 367 

cough in, 368 

diagnosis, 368 

discharge in, 367 

etiology, 366 

gastric disturbance in, 368 

latent form, 367 

pain in, 368 

pathology, 367 

prognosis, 368 

symptoms, 367 

tenderness in, 368 
suppuration, confined, 368. See also 
Suppuration, confined, of antrum of 
Highmore. 
treatment, 373 
of frontal sinus, 402 

purulent, acute, 402 

caries in, 404 

complications, 404 

diagnosis, 402 

discharge in, 403 

etiology, 402 

necrosis in, 404 

osteomyeltitis in, 404 

ostitis in, 404 

pain in, 403 

periostitis in, 404 

pus in, 403 

symptoms, 403 

transillumination in, 403 

treatment, 404 
chronic, 404 

diagnosis, 405 

discharge in, 405 

etiology, 404 

eye-symptoms in, 405 

mental condition in, 405 

mucous membrane in, 405 

pain in, 405 



Empyema of frontal sinus, purulent, chronic, 
pathology, 405 
prognosis, 405 
pus in, 405 
symptoms, 405 
suppuration, confined, 405. See also 
Suppuration, confined, of frontal 
sinus. 
of sphenoidal sinus, 395 
acute, 395 
chronic, 396 
delirium in, 396 
diagnosis, 397 
discharge in, 395 
ear-symptoms in, 396 
etiology, 395 
eye-symptoms in, 396 
gastric disturbance. in, 395 
headache in, 395 
loss of sleep in, 396 
pain in, 395 

rupture into adjacent cavities, 396 
suppuration of cavernous sinus from, 
397 
of pharyngeal bursa and, differen- 
tiation, 397 
suppurative meningitis in, 397 
symptoms, 395 
thinning of walls in, 396 
Thomwaldt's disease and, differen- 
tiation, 397 
tinnitus aurium in, 395 
treatment, 397 
vertigo in 395 
Enchondroma. See Chondroma. 
Enchondrosis of septum, hyperplastic rhinitis 

associated with, 118 
Endorhinitis, atrophic, 125 
Engorgement of mucous membrane in hyper- 
plastic rhinitis, 118 
Enlargement, glandular, in pharyngeal tonsil, 
458 
in tonsillar abscess, 482 
of blind spot in diseases of aecessorv sinuses, 

419 
of bronchial glands as cause of laryngismus 

stridulus, 645 
of cervical glands, tonsil and, relationship, 

492 
of faucial tonsil, 487. See also Tonsillitis, 

hypertrophic. 
of glands in hereditary nasal syphilis, 163 
of submaxillary lymphatic glands in primary 

stage of acquired nasal syphilis, 150 
of thyroid gland as cause of stenosis of 
pharynx, 520 
Enteric fever, acute simple rhinitis in, 83 
Enucleation, finger, of tonsil, 504 
Doyle's method, 507 
Richardson's method, 504 
Enunciation, hard and soft palate, tongue, 
and buccal cavities important factors in, 
747 
Epidemic influenza, 87. See also Influenza, 

epidemic. 
Epiglottis, chondritis of, 671 
in edematous laryngitis, 659 
in lupus of pharynx, 581 
turban, 706 
Epiglottitis, acute, 652 
symptoms, 653 
treatment, 653 
miasmatic, 641 
Epilepsy in hyperplastic rhinitis, 121 

neurosis, reflex nasal, 213 
Epipharyngeal periadenitis, chronic, 431. See 
also Periadenitis, epipharyngeal, chronic. 
tonsil, 457 
Epistaxis, 217 

after rupture of hematoma, 218 
amount of blood lost, 220 
character of flow, 220 



816 



INDEX. 



Epistaxis, complications, 221 
definition, 217 
diagnosis, 221 
etiology, 217 

constitutional conditions favoring, 218 
high altitude, 219 
local, 218 
trauma, 217 
vicarious, 219 
exit for blood, 220 
in atrophic rhinitis due to pre-existing 

lesion, 132, 133 
in fibroma of nasal cavities, 248 
in foreign bodies in nose, 227, 230 
in neurasthenia, 218 
in pharyngeal tonsil, 463 
in telangiectoma, 286 
occupation predisposing to, 218 
pathology, 219 
prognosis, 221 
sex predisposing to, 217 
site of predilection, 220 
symptoms, 220 

premonitory, 220 
syncope in, 221 
synonyms, 217 
treatment, 221 
unilateral or bilateral, 221 
varieties, 217 
Epithelial cells in cancer of nasal passage, 268 
tumors, embryonic, of respiratory tract, 
267 
Epithelioma, nasal, and rhinoscleroma, differ- 
entiation, 181 
of larynx and papilloma, differentiation, 237 
tubulated, of soft palate, 270 
Epithelium of vestibule, 24 
Equinia, 174 

of pharynx, 597 
Erysipelas, acute laryngitis in, 639 
prognosis, 639 
treatment, 639 
simple rhinitis in, 84 
in nasal lupus, 173 
of throat, 529 

pharynx in, 555. See also Pharynx in ery- 
sipelas. 
Erythema as symptom of syphilis of larynx, 
696 
exudativum of pharynx, 604 
in secondary syphilis of pharynx, 594 
multiform, of pharynx, 604 
neurosis, reflex nasal, 214 
Esophagoscope for adults, Jackson's, 719 
for infants and children, Jackson's, 719 
Kahler's, 727 
Esophagoscopy, Jackson's method, 721 
Esophagus, false teeth in, removal of. 722 
foreign bodies in, as cause of chondritis of 
larynx, 669 
of edematous laryngitis, 657 
paralysis of, and spasm of pharynx, differ- 
entiation, 617 
stricture of, and spasm of pharynx, differ- 
entiation, 617 
Essential anosmia, 192 
Ether anesthesia, 566 

rectal method, 468 
Ethmoid sinus, diseases of, diseases of eye 

from, 416, 417 
Ethmoidal cells, anatomy, 21 

sinuses, 21. See also Sinuses, accessory, 
ethmoidal. 
Ethmoiditis, eye signs, 419 
hyperplastic, chronic, 386 

asthma associated with, 386 
catarrhal conditions of middle ear and 
Eustachian tube associated with, 386 
diagnosis of, 386 
discharge from nose in, 386 
headache in, 386 
impairment of smell in, 386 



Ethmoiditis, hyperplastic, chronic, laryngitis 
associated with, 386 
pain in, 386 

pharyngitis associated with, 386 
symptoms, 386 
treatment, 386 
in epidemic influenza, 87, 88 
purulent, 387. See also Ethmoiditis, 

suppurating. 
suppurating, 387 

brain abscess in, 390 

complications, 390 

diagnosis, 390 

discharge in, 389 

etiology, 387 

eye-symptoms in, 389 

gastric disturbances in, 389 

impairment of smell in, 389 

infection of cranial cavity from, 390 

meningitis in, 389, 390 

mental derangement in, 389 

negative air-pressure in, 378 

opening into adjacent parts, 390 

orbital abscess in, 390 

pain in, 389 

pathology, 387 

prognosis. 390 

rupture in, 390 

swelling in, 389 

symptoms, 388 

thrombosis of cavernous sinus from, 390, 

391 
traumatism as cause, 387 
treatment, 391 
vaccine therapy in, 95 
Eustachian tube, catarrhal affections, asso- 
ciated with chronic hyperplastic eth- 
moiditis, 386 
in atrophic rhinitis due to lesion elsewhere, 
139 
to pre-existing lesion, 135 
involvement of, in atrophic nasopharyn- 
gitis, 438 
pharyngitis, 575 
in chronic nasopharyngitis, 430 
in hyperplastic nasopharyngitis, 440 
in hypertrophic tonsillitis, 489, 490 
in lupus of pharynx, 590 
in pharyngeal tonsil, 463 
occlusion of, from tonsillar abscess, 584 
Eversion of ventricles of larynx, 731 
Examination, 33 

arrangement of light, 33 
cocain as last resort in making, 41 
method of using tongue-depressor in, 39 
nasal, rules for, 39 
of floor of nose, position in, 36 
of larynx, 622. See also Larynx, examina- 
tion of. 
of middle turbinated body, position in, 36 
of superior portion of anterior nasal cavity, 

position in, 36 
position of patient, 34 
rhinoscopy, 35 
anterior, 35 
posterior, 36 
Exanthemata, pharynx in, 553 
Exhaustion as cause of congestion of mucous 

membrane, 114, 115 
Exostosis of respiratory tract, 245 
treatment, 246 
of septum, hyperplastic rhinitis associated 

with, 118 
of turbinates, 245 
Expiratory dyspnea from pressure on trachea, 

210 
Exudate in acute pharyngitis, 522 

increased, from mucous membrane, in con- 
stitutional diseases, 51 
serous, in cryptic tonsillitis, 474 
Exudation in atrophic rhinitis secondary to 
lesion elsewhere, 138 



INDEX. 



817 



Exudative pharyngitis, 560 
Eye affections, neuroses, reflex nasal, 213 
and nose, communication between, by 

lacrimal duct, 416 
diseases of, from diseases of ethmoid 
sinus, 416, 417 
from nasal obstruction, 417 
inflammation of nose from, 417 
in atrophic rhinitis due to pre-existing 
lesion, 135 
secondary to lesion elsewhere, 138 
relation of diseases of accessory sinuses to, 
416 
of nose to, 416 
signs of cavernous sinus thrombosis, 420 
of diseases of accessory sinuses, 419 
of ethmodititis, 419 
of frontal sinusitis, 419 
of maxillary sinusitis, 419 
of sphenoidal sinusitis, 419 
syphilitic disease, salvarsan in, 158 
Eye-complications in chronic simple rhinitis, 
109 
in hyperplastic rhinitis, 121 
Eye-lesions in hyperplastic rhinitis, 119 
Eyelids, edema of, from disease of accessory 

sinuses, 351 
Eye-muscles, paralysis of, from sinusitis, 351 
Eye-symptoms from diseases of accessory 
sinuses, 351 
in acute catarrhal inflammation of frontal 

sinus, 400 
in carcinoma of nose, 268 
in chronic catarrhal inflammation of frontal 
sinus, 401 
purulent inflammation of frontai sinus, 
405 
in confined suppuration of frontal sinus, 406 
in diseases of accessory sinuses, 354 
in empyema of sphenoidal sinus, 396 
in nasal polypus, 259 
in pharyngeal tonsil, 464 
in suppurating ethmoiditis, 389 



Face, emphysema of, from injury of turbinate 
bone, 113 
frog-, in fibroma of nasal passage, 249 
Face-ache in hyperplastic rhinitis, 119 
Facial contour, effect of, on voice, 732 
expression in cryptic tonsillitis, 476 
in diphtheria, 534 
in hypertrophic tonsillitis, 490 
in paralysis of pharynx, 618 
in pharyngeal tonsil, 462 
deformity from nasal polypus, 259 
in hereditary nasal syphilis, 164 
neuralgia dependent on nasal lesion, 53 
on sinus-lesion, 53 
Facies in atrophic rhinitis due to pre-existing 

lesion, 134 
False croup, 642, 644, 649 

membrane in fibrinoplastic rhinitis, 100, 101 
teeth, removal of, from esophagus, 722 
Farcy buds in glanders of pharynx, 598 
Farlow's tonsil-punch, 497, 498 
Farnham's forceps, 235 
Fatigue, cough of, 634 

predisposing to taking cold, 73 
Fauces, adenoma of, 239 
angioma of, 242 
hemorrhage in, 242 
treatment, 242 
herpes of, 455 

mycosis of, involving uvula, 448 
sarcoma of, 281 
spasmodic contraction, 453 
Faucial tonsil, 456, 470 

abscess of, chronic, 511 
treatment, 511 
tonsillar or peritonsillar, 482. See also 
Abscess, tonsillar. 



Faucial tonsil, actinomycosis of, 512 

as nidus for development of bacteria, 490 
atrophy of, 511 
cholesteatoma of, 509 
encysted abscess of, 511 
enlargement of, 487. See also Tonsil- 
litis, hypertrophic. 
fibroma of, 250 
foreign bodies in, 513 
gangrene of, 511 

hypertrophy of, 487. See also Tonsil- 
litis, hypertrophic. 
inflammatory diseases, acute, 470 

chronic, 487 
lipoma of, 253 
membranous inflammation, 485. See also 

Tonsillitis, membranous. 
mycosis of, 512. See also Mycosis of 
faucial tonsil. 
Fauvel's laryngeal polypus-forceps, 237 
Febrile diseases, pharynx in, 553 
Feeble-mindedness, defect of speech in, 754 
Ferguson's mouth-gag, 719 
sterilizer, 50 

tracheoscope for infants and children, 719 
Fetid catarrh, 125 
coryza, 125 
rhinitis, 125 
atrophic, 125 
chronic, 125 
Fetterolf's saw-file, 244 
Fever in acute glanders of pharynx, 598 

in retropharyngeal abscess, 603 
Fibrinoplastic inflammation of mucous mem- 
brane, 64 
membranous laryngitis, 661 
rhinitis, 100 

chronic form, 101 
etiology, 100 

false membrane in, 100, 101 
general remarks, 101 
treatment, 101 
Fibrinous croup, 661 
laryngitis, 661 
tonsillitis, 485 
ulcers, nasal, 190 
Fibroid degeneration, areas of, in acquired 

tertiary nasal syphilis, 152 
Fibroma of anterior nares, 248 
of antrum of Highmore, 383 
of ethmoidal sinuses, 393 
of frontal sinus, 415 
of larynx, 251 
diagnosis, 252 
etiology, 251 
irritation as cause, 251 
prognosis, 253 
symptoms, 252 
treatment, 253 
of nasal cavities, 247 

and chondroma, differentiation, 244 
and lupus, differentiation, 173 
associated with myxoma, 248 
diagnosis, 248 
epistaxis in, 248 
frog-face in, 249 
impairment of smell in, 248 
malignancy, 247 
nasal obstruction in, 248 
pain in, 248 
pathology, 248 
prognosis, 249 
site, 247 
treatment, 249 
voice in, 248 
of nasopharynx, 249 
diagnosis, 250 
prognosis, 250 
symptoms, 250 
treatment, 250 
of pharynx and cancer, differentiation, 272 
of respiratory tract, 247 



5-2 



818 



INDEX. 



Fibroma of respiratory tract and adenoma, 
differentiation, 240 
of tonsil, 250 
treatment, 251 
Fibromyxoma of nasopharynx, 263 
etiology, 263 
headache in, 263 
hemorrhage in, 263, 264 
nasal obstruction in, 264 
symptoms, 263, 264 
Fibrous bands in keratosis of pharynx, 610 
cicatrix in nasal lupus, 172 

tuberculosis, 167 
degeneration in chondritis of larynx, 675 
nasal polyp, 261. See also Myxofibroma, 

nasal. 
tissue in nasal leprosy, 178 
Finger enucleation of tonsil, 504 
Doyle's method, 507 
Richardson's method, 504 
Fistula in confined suppuration of antrum of 

Highmore, 369 
Flattening of nasal bridge in hereditary 

nasal syphilis, 163 
Fluctuation in tonsillar abscess, 484 
Fluid-retention, non-infected, of ethmoidal 

sinuses, 392 
Fluxus nasalis, 107 

Follicular laryngitis, 684. See also Laryn- 
gitis, follicular. 
pharyngitis, 566. See also Pharyngitis, 

follicular. 
tonsillitis, 474 
Folliculous pharyngitis, 566 
Forceps, Adams', 343 
alligator, 319 
alligator-jaw, 121 
Carter's chisel, 343 
Cohen's, 441 
Farnham's, 235 
Fauvel's, 237 
for foreign bodies, 229 
Jackson's cutting, 375 

endoscopic, 719 
Kyle's, for crushing septum, 300 
Mackenzie's laryngeal, 694 

throat, 694 
Mathieu's, 254 
Milbury's, 111 
Mosher's, 719 
Ostrom's, 375 
Roe's, 300 
Sajous', 719 
Scbroetter's, 252 
septal bone, 308 
Stucky's, 251 
tenacular-, 510 
Watson's tonsil-grasping. 495 
Foreign bodies as cause of acute rhinitis, 76 
of cough, 633 

of occupation pharyngitis, 549 
bronchoscopy for, 715 
cough from, 716 
diseases of bronchi from, 716 
drawn into respiratory tract during 

anesthesia, 715 
encysted, 715 
forceps for, 229 
in anterior nasal cavities, 224 
animate, 228 
diagnosis, 231 
discharge in, 230 
etiology, 228 

animate, mucous membrane 
in, 229 
pain and headache in, 230 
pathology, 229 
prognosis, 231 
symptoms, 230 
treatment, 231 
epistaxis in, 227, 230 
inanimate, 224 



Foreign bodies in anterior nasal cavities, in- 
animate, diagnosis, 228 
etiology, 226 

mucous membrane in, 226, 227 
pathology, 226 
prognosis, 228 
symptoms, 227 
treatment, 228 
in antrum of Highmore, 381. See also 
Antrum of Highmore, foreign bodies in. 
in esophagus as cause of chondritis of 
larynx, 669 
of edematous laryngitis, 657 
in faucial tonsil, 513 
in frontal sinus, 414. See also Frontal 

sinus, foreign bodies in. 
in larynx, 728. See also Larynx, foreign 

bodies in. 
in nose, ulcers due to, 186 
in pharynx, 619 
symptoms, 619 
treatment, 620 
instruments for removal of, 717 
metallic, removal, by magnet, 715 
pulmonary diseases from, 716 
Rontgen rays in detecting, 716 
Fossa of Rosenmuller, 26, 44 
Fossae, glosso-epiglottic, 625 
lingual, 625 
nasal, involvement of, in hyperplastic 

rhinitis, 119 
roofs of, in hyperplastic rhinitis, 119 
Fourth meatus, 21 
tonsil, 513 
turbinate, 19, fig. 1 
Frankel's pneumococcus, 71 
Freeman's syringe, 424 
Freer 's elevators, 308 
knife, 308 

operation for septal deviation, 320 
Friedlander's pneumobacillus, 71 

pneumococcus, 70 
Frog-face in fibroma of nasal passage, 249 
Frontal sinus, anatomy, 21 

catarrhal inflammation of, acute, 399 
diagnosis, 400 
etiology, 399 
eye-symptoms in, 400 
gastric disturbance in, 400 
headache in, 400 
pain in, 400 
pathology, 399 
prognosis, 400 
symptoms, 399 
tenderness in, 400 
treatment, 400 
chronic, 401 
diagnosis, 402 
discharge in, 402 
etiology, 401 
eye-symptoms in, -401 
mucous membrane in, 401 
pain in, 401 
pathology, 401 
prognosis, 402 
symptoms, 401 
tenderness in, 401 
treatment, 402 
confined suppuration of, 405. See also 
Suppuration, confined, of frontal sinus. 
cysts of, 415 
diseases of, 399 
empyema of, 402. See also Empyema 

of frontal sinus. 
fibroma of, 415 
foreign bodies in, 414 
animate, 414 
diagnosis, 414 
prognosis, 414 
symptoms, 414 
treatment, 414 
inanimate, 414 



INDEX. 



819 



Frontal sinus, foreign bodies in, inanimate, 
treatment, 414 
treatment, 414 

ifluminator for, 403 

infectious diseases of, 414 

infundibulum as outlet, 22 

involvement of, in epidemic influenza, 87 

mucocele of, 413. See also Mucocele of 
frontal sinus. 

myxoma of, 415 

osteoma of, 415 

pent-up pus in, 405 

tumors of, 415 
sinuses, 21. See also Sinuses, accessory, 

frontal. 
sinusitis, chronic, vaccine therapy in, 94 

eye signs, 419 
Functional aphonia, 766 
Fungus, ray, 67 

as cause of actinomycosis of pharynx, 600 
Furunculosis, nasal, 183 

definition, 183 

etiology, 183 

pathology, 183 

symptoms, 183; 

synonym, 183 

treatment, 183 



Ganglion*, sphenopalatine, neuralgia of, 357 

treatment, 357 
Gangrene in nasal glanders, 175 

of faucial tonsil, 511 
Gangrenous inflammation of mucous mem- 
brane, 65 
pharyngitis, 548. See also Pharyngitis, 
gangrenous. 
Gastric derangements in follicular pharyn- 
gitis, 570 
diseases as cause of congestion of mucous 

membrane, 114 
disturbances in actinomycosis of pharynx, 
601 
in acute catarrhal inflammation of 
frontal sinus, 400 
purulent inflammation of antrum of 
Highmore, 365 
in chronic nasopharyngitis, 429, 430 
purulent inflammation of antrum of 

Highmore, 368 
simple rhinitis, 109 
in empyema of sphenoidal sinus, 396 
in suppurating ethmoiditis, 389 
Gelatinous polypi, 265 
Germ-inheritance of nasal syphilis, 162 
Gersuny's paraffin method for correcting 

nasal deformities, 154 
Gibb's laryngeal ecraseur, 243 
Gland, thymus, pressure from, as cause of 

laryngismus stridulus, 645 
Glanders as cause of chondritis of larynx, 669 
bacillus of, 174 
nasal, 174 

abscesses in. 175 

and pyemia, differentiation, 176 

complication, 176 

definition, 174 

diagnosis, 176 

discharge in, 175 

etiology, 174 

gangrene in, 175 

granulation-tumors in, 174 

involvement of skin in, 175 

liquefaction-necrosis in, 175 

mucous membrane in, 175 

necrosis in, 175 

nodules in, 175 

pathology, 174 

pneumonia in, 176 

prognosis, 176 

symptoms, 175 

synonyms, 174 



Glanders, nasal, treatment, 176 
constitutional, 177 
ulcers in, 175, 189 
of antrum of Highmore, 379 
of ethmoidal sinuses, 393 
of mucous membrane, 67 
of nasopharynx, 597. See also Pharynx, 

glanders of. 
of pharynx, 597. See also Pharynx, 

glanders of. 
of tonsil, 597. See also Pharynx, glanders of. 
Glands, bronchial, enlargement of, as cause 
of laryngismus stridulus, 645 
enlargement of, in hereditary nasal syphilis, 

163 
mucous, amyloid degeneration, in kera- 
tosis of pharynx, 609 
of Bowman, 24 
of mucous membrane, 24 
of neck, involvement of, in sarcoma of 

tonsils, 281 
submaxillary lymphatic, enlargement of, 
in primary stage of acquired nasal 
syphilis, 150 
Glandular enlargement in pharyngeal tonsil, 
458 
involvement in acute glanders of pharynx, 
598 
in cancer of larynx, 276 
of nose, 268 
of pharynx, 272 
of soft palate, 270 
in chronic glanders of pharynx, 599 
in cryptic tonsillitis, 476 
in diphtheria, 534 
. in follicular pharyngitis, 568, 569 
in gangrenous pharyngitis, 549 
in membranous tonsillitis, 486 
in nasal lupus, 170 
in preglottic tonsillitis, 514 
in primary syphilis of pharynx, 594 
in tonsillar abscess, 482 
in tuberculosis, 167 
laryngitis, 684 

pharyngitis lateralis, 552. See also Phar- 
yngitis lateralis, glandular. 
Gleason's nasal speculum, 38 

operation for septal deviation, 316 
Glioma of nose, 286 
Globe inhaler, 48 
Globus hystericus simulated in chronic 

pharyngitis, 564 
Glosso-epiglottic fossa?, 625 

ligaments, 625 
Glossolabiolaryngeal paralysis, 618 
Glottic spasm, adenoids as cause of, 209 
Glottis, edema of, 656 

and membranous laryngitis, differen- 
tiation, 664 
from urticaria of pharynx, 605 
in occupation-pharvngitis, 550 
spasm of, 644, 648 

in acute laryngitis in children, 643 
in children, 646 
in elongation of uvula, 445 
in hyperplastic rhinitis, 121 
in intubation of larynx, 784 
in nasal hydrorrhea, 143 
Gliick's method of laryngectomy, 798 
Goblet-cells, 24 
Gottstein's adenoid curet, 469 
Gout cause of chondritis of larynx, 669 

pharynx in, 556 
Goutv diathesis predisposing to hay fever, 
199 
sore throat, 580, 584, 655 
throat, 655 

tonsillitis, 478. See also Tonsillitis, rheu- 
matic. 
Grant's scissors, 253 
Granular laryngitis, 684 
pharyngitis, 566 



820 



INDEX. 



Granulation-tumor in actinomycosis of phar- 
ynx, 600 
in nasal glanders, 174 
Granuloma, 145 

infectious, of mucous membrane, 66 

of pharynx, nasopharynx, and tonsils, 
586 
specific, of mucous membrane, 66 
Guillotine, 503 

Gumma in hereditary nasal syphilis, 163 
in syphilis of larynx, 697 
in tertiary period of acquired nasal syphilis, 
148 
Gumma-formation in tertiary syphilis of 
pharynx, 595 



Hacking cough, dry, 633 
Hay asthma, 194 

fever, 194. See also Rhinitis, hyper esthetic. 
Hays' pharyngoscope and laryngoscope, 42 
Head, cold in, 74 

symptoms of, 77 
Head-band, hard-rubber, 32 
Head-lamp, Phillip's, 33 
Head-light, Klaar's, 32 
Headache, congestive, reflex nasal, 213 
dependent on nasal lesion, 53 

on sinus-lesion, 53 
in acute glanders of pharynx, 598 

pharyngitis, 523 
in atrophic rhinitis secondary to lesion 

elsewhere, 138 
in catarrhal inflammation of sphenoidal 

sinuses, 394 
in chronic hyperplastic ethmoiditis, 386 
nasopharyngitis, 429 
simple rhinitis, 108 
in confined suppuration of frontal sinus, 

406 
in diphtheria, 533 

in diseases of accessory sinuses. 354, 357 
in emphysema of antrum of Highmore, 380 
in empyema of sphenoidal sinus, 395 
in fibromyxoma of nasopharynx, 263 
in foreign bodies in nose, 230 
in hay fever, 203 
in hyperplastic rhinitis, 119, 121 
in infective pharyngitis, 527 
in nasal hydrorrhea, 142 
in pharyngeal tonsil, 564 
in rheumatic tonsillitis, 479 
in secondary stage of acquired nasal syph- 
ilis, 150 
Hearing, impairment of, alteration in voice 
in, 739 
in acute nasopharyngitis, 423 

pharyngitis, 523 
in atrophic rhinitis due to pre-existing 

lesion, 134, 135 
in chronic nasopharyngitis, 429 
in follicular pharyngitis, 570 
in hyperplastic rhinitis, 119 
in sarcoma of nasopharynx, 280 
in secondary form of acquired nasal 
syphilis, 150 
importance of nasal breathing in relation 

to, 114 
muscles of, in chronic epipharyngeal peri- 
adenitis, 433 
objective, 739 

relation of nasal cavities to, 28 
of voice to, 738 

effect of drugs and stimulants in, 740 
subjective, 739 
teaching of, in deaf, 750 
Heart, affections of, as neuroses, reflex nasal, 

214 
Hematoma of larynx, 667 
of septum, 347 

treatment, 347 
rupture of, epistaxis after, 218 



Hematuria in diphtheria, 534 
Hemophilia after tonsillectomy, 499 
Hemoptysis in tuberculosis of larynx, 705 
Hemorrhage after tonsillectomy, 497 
treatment, 498, 499 
after uvulotomy, treatment, 446 
from varices of Ungual tonsil, 517 
in acute nasopharyngitis, 423 
in angioma of fauces, 242 

of nasal passage, 241 
in cancer of larynx, 276 

of nose, 268 
in chondroma of nasal passage, 244 
in fibromyxoma of nasopharynx, 263, 264 
in foreign bodies in larynx, 728 
in papilloma of larynx, 236, 237 
in rheumatic laryngitis, 655 
in sarcoma of larynx, 285 
of nasopharynx, 280 
of nose, 279 
of pharynx, 282 
in syphilis of larynx, 696 
laryngeal, 713 

and hemorrhagic laryngitis, differentia- 
tion, 666 
and pulmonary hemorrhage, differentia- 
tion, 714 
cough in, 713 
definition, 713 
diagnosis, 714 

differential, 714 
etiology, 713 
prognosis, 714 
respiration in, 713 
symptoms, 713 
treatment, 714 
voice in, 713 
pulmonary, and laryngeal hemorrhage, 

differentiation, 714 
secondary, after tonsillectomy, 498, 499 
Hemorrhagia narium, 217 
Hemorrhagic inflammation of larynx, 666 
of mucous membrane, 65 
laryngitis, 636, 666. See also Laryngitis, 

hemorrhagic. 
pharyngitis, 551. See also Pharyngitis, 

hemorrhagic. 
purpura of larynx, 642 
ulceration of pharynx, 551 
Hemostat, Corwin's tonsil, 499 
Hepatic cough, 634 
Hereditary syphilis of nose, 162. See also 

Nasal syphilis, hereditary. 
Heredity as cause of acute simple rhinitis, 75 
in chronic nasopharyngitis, 426 
in defects of speech, 751 
in enlargement of pharyngeal tonsil, 458 
in hypertrophic tonsillitis, 487 
Herxheimer reaction after intravenous injec- 
tion of salvarsan, 160 
Herpes, labial, in acute simple rhinitis, 77, 78 
of fauces, 455 

of pharynx, 605. See also Pharynx, 
herpes of. 
Herpetic tonsillitis, 480. See also Ton- 
sillitis, herpetic. 
ulcers, nasal, 185 
treatment, 185 
Hiatus semilunaris, 21, 22 

position of, fig. 5 
High altitude as cause of cyanotic phar- 
yngitis, 579 
of epistaxis, 219 
tracheotomy, 788 
Highmore, antrum of, 21, 22, 358. See also 

Antrum of Highmore. 
Hodgkin's disease as cause of stenosis of 

pharynx, 520 
Holmes' nasopharyngoscope, 42 
Horse fever, 194, 210 
Hospital sore throat, 526 
Hot-air apparatus, 48 



INDEX. 



821 



Hot-air apparatus, electric, 49 
Hutchinson's teeth in hereditary nasal syph- 
ilis, 163 
Hyaline change in keratosis of pharynx, 

611 
Hydroma, 288 

Hydropic degeneration in edematous laryn- 
gitis, 658 
Hydrops antri, 361, 368 

symptoms like mucocele of antrum of 
Highmore, 382 
Hydrorrhea, nasal, 141, 194 
acute, 74 
attacks, 143 
nasal, chronic, 107 
complications, 143 
constitutional symptoms, 143 
cough in, 143 
definition, 141 
diagnosis, 143 
discharge in, 142 
etiology, 141 
headache in, 142 

idiopathic, as reflex nasal neurosis, 194 
mucous membrane in, 142 
pain in, 143 
pathology, 142 
periodicity of attacks, 142 
polypi complicating, 143 
prognosis, 143 
remissions in, 143 
sneezing in, 142 
spasm of glottis in, 143 
symptoms, 142 
synonyms, 141 
treatment, 143 
Hydrorrhcea nasalis, 141 
Hygroma, 288 
Hyperacid saliva, 56 
Hyperemia of larynx, 690. See also Larynx, 

hyperemia of. 
Hyperesthesia in nasal membrane in hay 
fever, 202 
of larvnx, 762 

treatment, 762 
of pharynx, 616 

treatment, 616 
of soft palate, 453 
Hyperesthetic rhinitis, 104, 194. See also 

Rhinitis, hyperesthetic. 
Hyperkeratosis of pharynx, 608 
Hyperosmia, 192 
Hyperplasia in chronic pharyngitis, 563 

of lingual tonsil, 516. See also Lingual 

tonsil, hyperplasia of. 
of mucous membrane in reflex nasal asthma, 

213 
syphilitic, of pharynx, congenital, 592, 593 
treatment, 593 
Hyperplastic change in pharynx, 572 

ethmoiditis, chronic, 386. See also Eth- 

moiditis, hyperplastic, chronic. 
laryngitis, 688. See also Laryngitis, hyper- 
plastic. 
nasopharyngitis, 440 
etiology, 440 

involvement of Eustachian tube in, 440 
symptoms, 440 
treatment, 440 
rhinitis, 116. See also Rhinitis, hyper- 
plastic. 
tissue, appearance of, in hyperplastic 

rhinitis, 118, 119 
tonsillitis, 487 
Hypersecretion in hyperplastic rhinitis, 119 
Hypertrophic laryngitis, 688 
nasal catarrh, 116 
ozena, 116 
rhinitis, 108, 116 

chronic, 116 
tonsillitis, 487. See also Tonsillitis, hyper- 
trophic. 



Hypertrophy in follicular pharyngitis, 568 
of faucial tonsil, 487. See also Tonsillitis. 

hypertrophic. 
of laryngeal tissue, 629, 688 

treatment, 629 
of turbinates, 116 

polypoid, and nasal polypus, differen- 
tiation, 259 
Hypo-acid saliva, 56 
Hysteria, spasm of larynx in, 648 
Hysterical aphonia, 763 

and spastic dyspnea, 765 
definition, 763 
diagnosis, 763 
treatment, 765 
cough, 633 



Idiosyncratic coryza, 194 
Illumination, 30 

in laryngectomy, 797 
light for, 30 
mirrors for, 31 
reflecting, 31 
pocket set, 31 
Welsbach light for, 30 
Imbedded tonsil, 491 

Immunity, Colle's law of, in nasal syphilis, 
146 
in diphtheria, 541 

Profeta's law of, in nasal syphilis, 146 
Index, opsonic, 94 

Indolent bubo in acquired nasal syphilis, 150 
Infection of accessory sinuses, 350 
Infections, acute, of sphenoidal sinuses, 398 
Infectious diseases, acute, antrum of High- 
more in, 379 
nasopharyngitis after, 422 
rhinitis in, 75 
as cause of edematous laryngitis, 657 
catarrhal conditions after, 73 
chronic nasopharyngitis after, 426 
hypertrophic tonsillitis after, 487 
of frontal sinus, 414 
predisposing to taking cold, 73 
preglottic tonsillitis after, 514 
susceptibility to, in pharyngeal tonsil, 563 
tonsillar abscess in, 482 
granuloma of mucous membrane, 66 

of pharynx, nasopharynx, and tonsils, 
586 
inflammations, chronic, 66 
Infective pharyngitis, 526. See also Pharyn- 
gitis, infective. 
Infiltration, acute, of uvula, 446 
submucous, of septum, 335 
watery, in tonsillar abscess, 482 
Inflammation, 59 

catarrhal, acute, of frontal sinus, 399. See 
also Frontal sinus, catarrhal inflam- 
mation of, acute. 
chronic, of frontal sinus, 401. See also 
Frontal sinus, catarrhal inflammation of, 
chronic. 
of antrum of Highmore, 359. See also 
Antrum of Highmore, catarrhal in- 
flammation. 
of ethmoidal sinuses, 385 
diagnosis, 385 
symptoms, 385 
treatment, 386 
of sphenoidal sinuses, 394. See also 
Sphenoidal sinuses, catarrhal inflam- 
mation. 
hemorrhagic, of larynx, 666 
infectious, chronic, 66 

membranous, non-infectious, in acute phar- 
yngitis, 522 
of faucial tonsil, 485. See also Ton- 
sillitis, membranous. 
of antrum of Highmore, purulent, acute, 364. 
See also Empyema of antrum of Highmore. 



822 



INDEX. 



Inflammation of antrum of Highmore, puru- 
lent, chronic, 366. See also Empyema of 
antrum, of Highmore. 
of larynx, chronic, 694 
of lingual tonsil, acute, 514. See also 

Tonsillitis, preglottic. 
of mucous membrane, 60. See also Mucous 

membrane, inflammation of. 
of nasopharynx, specific, 442 
of nose, spread of, through lacrimal duct, 

417 
phlegmonous, acute, of lingual tonsil, 515 

of antrum of Highmore, 384 
purulent, acute, of frontal sinus, 402. See 
also Empyema of frontal sinus. 
chronic, of frontal sinus, 404. See also 
Empyema of frontal sinus. 
specific, 145 

of ethmoidal sinuses, 393 
processes, 66 
suppurative, chronic, of frontal sinus, 404. 
See also Empyema of frontal sinus, puru- 
lent, chronic. 
Inflammatory diseases, acute, of anterior 
nasal cavities, 72 
chronic, of anterior nasal cavities, 107 
of anterior nasal cavities, 184 
of faucial tonsil, acute, 470 

chronic, 487 
of larynx, 632 
of uvula, 446 
processes in hyperplastic rhinitis, 118 
Influenza, acute laryngitis in, 641 
epidemic, 87 
coryza in, 87 

effect of, on tissue and function, 89 
ethmoiditis in, 87, 88 
involvement of accessory cavities in, 88 
of frontal sinus in, 87 
of tonsils in, 88 
lesions after, 89 
mucous membranes in, 88 
peritonsillar involvement in, 88 
Pfeiffer's bacillus in, 87 
synonym, 87 
thickening of mucous membrane after, 

89 
treatment, 89 
in chronic epipharyngeal periadenitis, 434 
pharynx in, 557 
preglottic tonsillitis after, 514 
Infundibulum, outlet of frontal sinus, 22 

position of, fig. 5 
Ingal's laryngeal speculum, 683 

operation for septal deflection, 314 
Inhaler, 47 
Coulter's, 49 
Globe, 48 
Injuries of nose, reflex nasal asthma after, 
210 
of turbinate bone, emphysema of face from, 
113 
Instruments for office work, 45 
cleanliness of, 49 
sterilization of, 49 
Insufficiency, congenital, of palate, 449 

treatment, 450 
Intellect as factor in objective sound-percep- 
tion, 742 
Intermittent feA r er, pharynx in, 556 

treatment, 556 
Intestinal derangements in follicular phar- 
yngitis, 570 
irritation, congested mucous membrane in, 

51 
tonsils, 538 
Intracranial anosmia, 192 

complications of empyema of antrum of 
Highmore, 373 
Intravenous injection of neosalvarsan, 159 
apparatus for, 159 
of salvarsan, 158 



Intravenous injection of salvarsan, apparatus 
for, 159 
Herxheimer reaction after, 160 
Intubation of larynx, 777. See also Larynx, 

intubation of. 
Intumescent rhinitis, 115. See also Rhinitis, 

intumescent. 
Iodid of potassium and salvarsan in tertiary 

syphilis, 157 
Isthmus of nasopharynx, 26 
Itching in intumescent rhinitis, 115 

in nasal lupus, 172 



Jackson's aspirator for esophagoscopes, 719 
bronchoscope, 716 

for adults, 719 
cutting-forceps, 375 
endoscopic forceps, 719 
esophagoscope for adults, 719 

for infants and children, 719 
method of bronchoscopy, 718 
of direct laryngoscopy, 727 
of esophogoscopy, 721 
of laryngo-bronchoscopy, 718 
of lower bronchoscopy, 727 
of postoperative care after laryngec- 
tomy; 801. See also Laryngectomy. 
position for laryngectomy, 798 
slide speculum, 719 
Jaw, lumpy, 600 

Joints, effect of excessive alkalinity of secre- 
tions on, 58 

in acute glanders of pharynx, 598 
Jugular veins, thrombosis of, from tonsillar 

abscess, 484 
June cold, 194 



Kahler's esophagoscope, 727 
Keen's method of laryngectomy, 798 

silver tracheotomy tube, 787 
Keloid, nasal, and rhinoscleroma, differen- 
tiation, 181 
Keratin, 611 

Keratohyaline in keratosis of pharynx, 610 
Keratosis of nasopharynx, 608. See also 
Pharynx, keratosis of. 

of pharynx, 608. See also Pharynx, kera- 
tosis of. 

of tonsil, 608. See also Pharynx, keratosis of. 
Killian's operation for confined suppuration of 
frontal sinus, 410 
after-treatment, 412 
for septal deviation, 317 
Kirstein's method of autoscooy, 626 
Klaar's headlight, 32 
Klebs-L6ffler bacillus, 70 
Knife. Allen's, 305 

Asch's, 111 

Freer's, 308 

Kyle's septum-, 111 

Stevens', 496 

swivel, 320 

tonsil, 501 
Koch, bacillus of, 166 
Kussmaul's definition of stuttering, 752 
Kyle's adenoid curet, 469 

forceps for crushing septum, 300 

long nasal tube, 303 

in position, 303 

malleable nasal tube, 299 

method of examining larynx, 622 
of tonsillectomy, 500-502 

nasal saw, 121 

postnasal lamp, 41 

septum-knife, 111 

Labial herpes in acute simple rhinitis, 77, 78 
Labioglossopharyngeal paralysis, 454 



INDEX. 



823 



Lacrimal canal, occlusion of, in hyperplastic 
rhinitis, 119 
duct, communication between eve and nose 
by, 416 
in atrophic rhinitis secondary to lesion 

elsewhere, 139 
position of, 22, fig. 5 

spread of inflammation of nose through, 
417 
Lacrimation in secondary stage of acquired 
nasal syphilis, 150 
reflex nasal, 213 
Lactic bacteriotherapy in pharyngeal affec- 
tions, 528 
Lactic-acid bacteria in treatment of atrophic 
rhinitis due to pre-existing local lesion, 136 
Lacunae, tonsillar, 26 
Lacunar diphtheria, 535 
tonsillitis, 471, 474 
ulcerative, 471 
La grippe, 87 

pharynx in, 557 
Lallation, 749 
Lalopathy, 749 
Laloplegia, 749 
Lamp, Kyle's postnasal, 41 
Language and thought, relation of, 747 
Laryngeal bed-sore in chondritis of larvnx, 669 
cough, 633, 634 
diphtheria, 661 
hemorrhage, 713. See also Hemorrhage, 

laryngeal. 
nerve, recurrent, 771 
nerves, superior, paralysis of, 769 
diagnosis, 769 
prognosis, 769 
symptoms, 769 
treatment, 769 
nystagmus, 766 
occlusion, spasmodic, 767 
rheumatism, 655 
tissue, hypertrophy of, 629, 688 

treatment, 629 
tonsil, 456, 517 
tuberculosis, 703 
ventricles, prolapse of, 730 
vertigo, 767 
prognosis, 768 
synonym, 767 
treatment, 768 
Laryngectomy, 797 

artificial larynx after, 803 
general preparation of patient, 797 
Gluck's method, 798 
illumination in, 798 
indications, 797 

Jackson's method of postoperative care, 
801 
position, 798 
Keen's method, 798 
operation, 798 
partial, 803 
Perier's method, 800 
position of patient, 798 
postoperative factors, 801 
unilateral, 803 
Laryngendoscope, 627 
Laryngismus stridulus, 644 

as neurosis of nasopharynx, 442 

caries of vertebras as cause, 645 

definition, 644 

disease of tongue as cause, 645 

elongation of uvula as cause, 645 

enlargement of bronchial glands as cause, 

645 
etiology, 644 
in tabes, 645 

paralysis of erico-arytenoid muscle in, 645 
pressure from thymus gland as cause, 645 
synonyms, 644 
treatment, 645 
uric-acid diathesis as cause, 645 



| Laryngitis, acute, in children, 642 

cough in, 643 

diagnosis, 643 

etiology, 643 

spasm of glottis in, 643 

symptoms, 643 

synonyms, 642 

treatment, 643 

voice in, 643 
in constitutional diseases, 639 
in erysipelas, 639 

prognosis, 639 

treatment, 639 
in influenza, 641 
in malaria, 641 
in measles, 640 

prognosis, 640 

treatment, 640 
in rheumatism, 642 
in scarlet fever, 640 
in small-pox, 640 
in typhoid fever, 641 
in typhus fever, 640 
atrophic, 685 
catarrhal, 649 
acute, 634 

cough in, 636 

definition, 634 

diagnosis, 636 

etiology, 634 

interference with phonation in, 636 

mucous membrane in, 635 

pathology, 635 

prognosis, 637 

secretion in, 635 

suffocative attacks in, 636 

symptoms, 636 

synonyms, 634 

temperature in, 636 

throat in, 636 

treatment, 637 

voice in, 636 
chronic, 677 

and carcinoma of larvnx, differentiation, 

682 
and edema of larynx, differentiation, 681 
and paralysis of larvnx, differentiation, 

681 
and syphilitic laryngitis, differentiation, 

681 
and tubercular laryngitis, differentia- 
tion, 681 
definition, 677 
diagnosis, 681 

differential, 681 
etiology, 677 

in elongation of uvula, 445 
pathology, 679 

contraction of organized tissue, 679 

increase due to engorged vessels, 679 

permanent increase of tissue, 679 
prognosis, 682 
secretion in, 680 
symptoms, 680 
synonym, 677 
treatment, 682 
ulceration in, 681 
voice in, 678, 679, 680 
croupous, 661 
cyanotic, 688 
prognosis, 688 
symptoms, 688 
synonyms, 688 
treatment, 688 
diphtheritic, 661 
drv, 685 

cough in, 686 
definition, 685 
diagnosis, 687 
etiology, 685 
prognosis, 687 
secretion in, 686 



824 



INDEX. 



Laryngitis, dry, spreading of, 685 

symptoms, 686 
day, 686 
night, 686 

synonyms, 685 

treatment, 687 

true atrophy rare in larynx, 686 

voice in, 686 
edematous, 656 

angioneurotic, 656 

cardiac lesions as cause, 657 

chondritis as cause, 657 

cough in, 659 

definition, 656 

diagnosis, 659 

dyspnea in, 658 

epiglottis in, 659 

etiology, 656 

foreign bodies in esophagus as cause, 657 

hydropic degeneration in, 658 

in acute thyroiditis, 657 

infectious diseases as cause, 657 

leukocytes in, 657 

operations as cause, 657 

pain in, 659 

pathology, 658 

perichondritis as cause, 657 

prognosis, 659 

respiration in, 658 

symptoms, 658 

synonyms, 656 

treatment, 659 

varieties, 656 

voice in, 658 
fibrinoplastic, 661 
fibrinous, 661 
follicular, 684 

associated with follicular pharyngitis, 
684 

cough in, 684 

definition, 684 

diagnosis, 684 

etiology, 684 

pathology, 684 

prognosis, 684 

secretion in, 684 

symptoms, 684 

synonyms, 684 

treatment, 685 

voice in, 684, 685 
glandular, 684 
granular, 684 
hemorrhagic, 636, 666 

and hemorrhage of larynx, differen- 
tiation, 666 

cough in, 667 

diagnosis, 668 
differential, 668 

irritation in, 667 

pathology, 667 

prognosis, 668 

saliva in, 667 

symptoms, 667 

synonym, 666 

treatment, 668 

voice in, 667 
hyperplastic, 688 

in syphilis, 689 

symptoms, 688 

tissue-change in, 689 

treatment, 689 
hypertrophic, 688 
in chronic hyperplastic ethmoiditis, 386 

pharyngitis, 565 
lithemic, 655 
membranous, 661 

and capillary bronchitis, differentiation, 
665 

and diphtheria, differentiation, 662, 664 
resemblance, 662 

and edema of glottis, differentiation, 664 
of larynx, differentiation, 664 



Laryngitis, membranous, and foreign bodies 
in larynx, differentiation, 665 

and retropharyngeal abscess, differen- 
tiation, 664 

and tonsillitis, differentiation, 665 

and whooping-cough, differentiation, 665 

bacteria as cause, 661 

contagiousness, 662 

cough in, 663 

diagnosis, 664 
differential, 664 

dyspnea in, 663, 664 

etiology, 661 

exudate in, 663 

false membrane in, 663 

fever in, 663 

in children, 662 

pathology, 663 

prognosis, 665 

pulmonary symptoms, 664 

respiration in, 663 

skin in, 663, 664 

symptoms, 663 

synonyms, 661 

treatment, 665 
surgical, 666 

varieties, 661 

voice in, 663 
phlegmonous, 654, 656 
pseudomembranous, 661 
purulent, 654, 656 
rheumatic, 655 

hemorrhage in, 655 

lassitude in, 656 

pain in, 655 

synonyms, 655 

treatment, 656 

voice in, 655 
sicca, 685 
spasmodic, 644, 649 

and pseudomembranous croup, differ- 
entiation, 651 

catarrhal pneumonia after, 651 

cough in, 651 

definition, 649 

diagnosis, 651 
differential, 651 

etiology, 650 

occurring at night, 650 

pathology, 650 

prognosis, 651 

pulse in, 650 

symptoms, 650 

synonyms, 649 

treatment, 651 

voice in, 651 
specific, 694 
stridulosa, 649 
stridulus, 649 
subglottic, 642 
suppurative, 654, 656 

choking in, 655 

cough in, 655 

cyanosis in, 655 

diagnosis, 655 
differential, 655 

difficult swallowing in, 655 

pain in, 654 

pathology, 654 

prognosis, 655 

purulent, 656 

respiration in, 655 

symptoms, 654 

synonyms, 654 

treatment, 655 

voice in, 655 
supraglottic, acute, 642 
symptomatic, 688 

syphilitic, and chronic laryngitis, differ- 
entiation, 682 
traumatic, 653 

edema in, 653 



INDEX. 



825 



Laryngitis, traumatic, treatment, 654 
tubercular, 703 

and chronic laryngitis, differentiation, 681 
and syphilis of larynx, differentiation, 700 
ulcerative, recurrent, 696 
Laryngobronehoscopy, Jackson's method, 718 
Laryngocele, 629 
Laryngopharynx, 18 
Laryngorrhea, 634 
Laryngoscope, 32 

Hays', 42 
Laryngoscopy, direct, Jackson's method, 727 
Laryngotomy, 790 
Laryngotracheal diphtheria, treatment, 545 

ozena, 686 
Laryngotracheitis, 661 
Larynx, 18 

adenoma of, 240 

developing into malignancy, 240 
anemia of, 689 
diagnosis, 690 
prognosis, 690 
treatment, 690 
voice in, 690 
anesthesia of, 760 
diagnosis, 760 
etiology, 760 
prognosis, 761 
symptoms, 760 
treatment, 761 
angioma of, 243 

treatment, 243 
artificial, after laryngectomy, 803 
carcinoma of, 273. See also Carcinoma of 

larynx. 
catarrh of, acute, 634 

chronic, 677 
cellulitis of, acute, 656 
chondritis of, 668 

and chondroma, differentiation, 245 
diagnosis, 675 

differential, 675 
due to exposure to cold, 675 
due to rheumatism, 675 
due to syphilis, 675 
due to traumatism, 675 
due to tuberculosis, 675 
due to tvphoid fever, 675 
etiology, 668 

actinomycosis, 669 
exposure to cold, 669 
foreign bodies in esophagus, 669 
glanders, 669 
gout, 669 

infected emboli, 669 
pressure in aged, 669 
pyemic metastasis in typhoid, 669 
rheumatism, 669 
specific inflammations, 669 
syphilis, 669 
traumatism, 668 
tuberculosis, 669 
tumors of larvnx, 669 
pathology. 669 

due to rheumatism, 671 
due to syphilis, 669 
due to traumatism, 671 
due to tuberculosis, 670 
due to typhoid fever, 670 
order of involvement of cartilage, 671 
prognosis, 676 

due to exposure to cold, 676 
due to rheumatism, 676 
due to syphilis, 676 
due to traumatism, 676 
due to tuberculosis, 676 
due to typhoid fever, 676 
symptoms, 671 

due to exposure to cold, 674 
due to rheumatism, 674 
due to syphilis, 671 
due to traumatism, 674 



Larynx, chondritis of, symptoms, due to tuber- 
culosis, 671 
due to typhoid fever, 672 

emphysema of tissues of neck 
in, 673 
fibrous degeneration, 675 
special, due to arytenoid, 674 
due to cricoid, 674 
due to thyroid, 674 
treatment, 676 

due to exposure to cold, 677 
due to rheumatism, 677 
due to syphilis, 676 
due to traumatism, 677 
due to tuberculosis, 676 
due to typhoid fever, 677 
chondroma of, 245 

and carcinoma, differentiation, 245 
and perichondritis, differentiation, 245 
diagnosis, 245 

differential, 245 
prognosis, 245 
treatment, 245 
chorea of, 766 
synonym, 766 
treatment, 767 
consumption of, 703 
cyanotic congestion of, 657 
deformities of, 628 
diseases of, 621 

edema of, and chronic laryngitis, differen- 
tiation, 681 
and membranous laryngitis, differen- 
tiation, 664 
angioneurotic, 688 
chronic, 657, 661, 688 
treatment, 661 
epithelioma of, and papilloma, differen- 
tiation, 237 
examination of, 622 
autoscopv in, 626 
Kvle's method, 622 
parts seen, 625, 626 
patient closing eyes, 623 

standing, 623 
position of mirror, 625 
size of mirror, 625 
fibroma of, 251. See also Fibroma of larynx 
foreign bodies in, 728 

and membranous laryngitis, differen- 
tiation, 665 
and pulmonary phthisis, differentia- 
tion, 729 
animate, 728 
cough in, 728 
diagnosis, 729 

differential, 729 
emphvsema of neck in, 728 
fluid, 728 

hemorrhage in, 728 
inanimate, 728 
prognosis, 729 
solid, 728 
symptoms, 728 
treatment, 730 
voice in, 728 
hematoma of, 667 
hemorrhage of, and hemorrhagic laryngitis, 

differentiation, 666 
hemorrhagic inflammation, 666 
hyperemia, 690 
etiology, 690 
pathology, 690 
treatment, 690 
voice in, 690 
hyperesthesia of, 762 

treatment, 762 
in production of voice, 737 
inflammations of, chronic, 694 
inflammatory diseases of, 632. See also 

Laryngitis. 
intubation of, 777 



826 



INDEX. 



Larynx, intubation of, accidents, 784 
complications, 784 
dangers, 784 
definition, 777 
indications, 777 
instruments for, 778 
method, 782 

O'Dwyer's instruments for, 778 
position of patient and operator, 782 
postoperative care, 784 
removal of tube, 785 
sequels, 785 
spasm of glottis in, 784 
Thorner's instruments for, 779 
involvement of, in chronic rheumatic phar- 
yngitis, 584 
irritation of, in nasal polypus, 259 
lipoma of, 254 
lupus of, and syphilis, differentiation, 700 

and tuberculosis, differentiation, 707 
malformations of, 627 

malignant disease of, and chronic laryn- 
gitis, differentiation, 682 
mucocele of, 265. See also Mucocele of 

larynx. 
mucous membrane of, effect of climate on, 

580 
neuralgia of, 762 
treatment, 763 
neuroses of, 759 
operations on, 794 

dangers, 796 
pain in, 762 
papilloma of, 235. See also Papilloma of 

larynx. 
paralysis of, and chronic laryngitis, differ- 
entiation, 681 
as cause of cough, 633 
bilateral abductor, 772 
diagnosis, 773 
etiology, 772 
prognosis, 773 
symptoms, 773 
treatment, 773 
adductor, 775 
central adductor, 774 
internal tensors, 775 
muscles, 774 
prognosis, 776 
treatment, 776 
recurrent, 769 
diagnosis, 771 
etiology, 771 
prognosis, 772 
symptoms, 771 
treatment, 772 
unilateral abductor, 774 
prognosis, 774 
symptoms, 774 
treatment, 774 
adductor, 775 
paresthesia of, 761 
pemphigus of, 690 

treatment, 691 
perichondritis of, 668. See also Larynx, 

chondritis of. 
posterior wall, inspection of, 627 
pouches of, dilatation, 629 
purpura haemorrhagiea of, 642 
reflex nasal neuroses of, 209 
sarcoma of, 284. See also Sarcoma of 

larynx. 
scleroma of, 689 

and rhinoscleroma, 689 
cough in, 689 
definition, 689 
symptoms, 689 
synonym, 689 
treatment, 689 
size of, controlling volume, tone, and timbre 

of voice, 737 
spasm of, 644, 648, 649 



Larynx, spasm of, adenoids as cause, 209 
diagnosis, 649 
dyspnea in, 648 
etiology, 648 
in children, 646 

convulsions in, 647 

diagnosis, 647 
differential, 647 

dyspnea in, 647 

etiology, 646 

nutrition in, 647 

opisthotonos in, 647 

pathology, 647 

prognosis, 647 

respiration in, 647 

symptoms, 647 

synonyms, 646 

treatment, 647 
in hysteria, 648 

prognosis, 649 

symptoms, 648 

synonym, 648 

treatment, 649 
spastic paraplegia of, 767 
stenosis of, acquired, 629 

cicatricial contraction or redundant 
granulation as cause, 629 
treatment, 630 

cough in, 630 

etiology, 629 

pain in, 630 

syphilis in larynx as cause, 630 

treatment, 631 
congenital, 628 

treatment, 628 
from tuberculosis, 705 
in leprosy, 632 
in lupus, 631 

prognosis, 631 

treatment, 631 
syphilitic, treatment of, 703 
tuberculous, 631 
stridor of, congenital, 646 

etiology, 646 

symptoms, 646 
suppuration of, 654 
surgery of, 794 
syphilis of, 694 

and carcinoma, differentiation, 700 

and lupus, differentiation, 700 

and tuberculosis, differentiation, 700, 707 

cough in, 695 

definition, 694 

dysphagia in, 696 

dyspnea in, 696 

etiology, 695 

gumma in, 697 

hemorrhage in, 696 

pain in, 696 

paralysis of vocal cords in, 695 

pathology, 695 

prognosis, 700 

salvarsan in, 703 

secretion in, 695 

symptoms, 695 

condyloma, 697 

erythema, 696 

mucous patch, 697 

superficial ulcer, 696 
synonyms, 694 
tenderness in, 696 
tertiary, 697 

cicatrization in, 699 

treatment ,702 

ulceration in, 698 
treatment, 701 
voice in, 695 

Wassermann reaction in, 700 
tracheotomy of, 786. See also Tracheotomy. 
trachoma of, 691 
tuberculosis of, 703 

and carcinoma, differentiation, 707 



INDEX. 



827 



Larynx, tuberculosis of, and lupus, differentia- 
tion, 707 
and syphilis, differentiation, 707 
bacillus of tuberculosis as cause, 703 
choking in, 705 
cough in, 705 
course, 704 
definition, 703 
diagnosis, 707 

dysphagia in, alcohol injection for, 712 
dyspnea in, 705 
etiology, 704 
hemoptysis in, 705 
involvement of arytenoids in, 706 
of epiglottis in, 706 
of vocal cords in, 707 
mucous membrane in, 706 
pain in, 705 
pathology, 704 
primary infection, 704 
prognosis, 708 
secretion in, 705 
stenosis from, 705 
swallowing in, 705 
swelling in, 706 
symptoms, 704 
synonyms, 703 
treatment, 708 
ulceration in, 706 
voice in, 705 
tumors of, as cause of chondritis of larynx, 
669 
of cough, 633 
diagnosis, early, importance of, 794 
microscopic examination, before opera- 
tion, 795 
ventricles of, eversion, 730 
Lateralis nasi artery, 290 

Law, Colles', of immunity, in nasal syphilis, 
146 
Profeta's, of immunity, in nasal syphilis, 
146 
Layer, connective-tissue, of basement mem- 
brane, 59 
Layers of mucous membrane of accessory 

sinuses, 23 
Lepra, 177 

Leprosy, bacillus of, 177 
nasal, 177 

and syphilis, differentiation, 179 
anesthetic variety, 177 
pathology, 177 
prognosis, 179 
cells in, 178 

cicatricial tissue in, 179 
diagnosis, 179 
etiology, 177 
fibrous tissue in, 178 
liquefaction-necrosis in, 178 
modes of inoculation, 177 
mucous membrane in, 178 
nodules in, 178, 179 
pathology, 177 
prognosis, 179 
symptoms, 178 
synonyms, 177 
treatment, 179 
tubercular variety, 177 
pathology, 177 
prognosis, 179 
ulceration in, 179 
voice in, 178 
of mucous membrane, 68 
stenosis of larynx in, 632 
Leprous ulcers, nasal, 189 
Leptothrix as cause of pharyngomycosis, 606 
buccalis as cause of mycosis of faucial 
tonsil, 512 
of lingual tonsil, 516 
Leukocytes in acute simple rhinitis, 76 
in chronic simple rhinitis, 108 
in edematous laryngitis, 657 



Leukoplakia buccalis, 270 
Lewis' electric sterilizer, 50 
septum chisel, 308 
tonsil snare, 502 
Ligaments, glosso-epiglottic, 625 
Light for illumination, 30 

Welsbach, 30 
Lingual fossae, 625 
tonsil, 456, 513 
anatomy, 514 
examination, in diagnosis of diphtheria, 

537 
hyperplasia of, 516 
diagnosis, 516 
symptoms, 516 
treatment, 516 
inflammation of, acute, 514. See also 
Tonsillitis, preglottic. 
phlegmonous, 515 
deglutition in, 515 
diagnosis, 516 
pain in, 515 
symptoms, 515 
treatment, 516 
involvement of, in acute pharyngitis, 523 
mycosis of, 516 
etiology, 516 

Leptothrix buccalis, 516 
treatment, 516 
ulceration in, 516 
synonym, 513 
varices, 517 

absence of rales in, 517 
alcoholism as cause, 517 
as cause of peculiar subjective sen- 
sations, 517 
etiology, 517 
hemorrhage from, 517 
in menopause, 517 
in pregnancy, 517 
rupture, 517 
treatment, 517 
Lipoma of larynx, 254 
of nares, 253 
of nasopharynx, 253 
of pharynx, 253 
of respiratory tract, 253 
of tonsil, 253 
Liquefaction-necrosis in cryptic tonsillitis, 475 
in infective pharyngitis, 527 
in nasal glanders, 175 
leprosy, 178 
tuberculosis, 167 
Lisping, 749, 753 

Lithemia in acute rheumatic pharyngitis, 581 
Lithemic condition in taking cold, 73 
laryngitis, 655 
pharyngitis, 580 
rhinitis, 90, 194 
treatment, 90 

chemical analysis of secretions in, 90 
constitutional, 90 
local, 90 
Liver, involvement of, in cyanotic rhinitis, 144 
torpid, as cause of chronic nasopharyngitis, 
426 
Llewellyn's modification of Bergson's atom- 
izer, 46 
Lockjaw and tonsillar abscess, resemblance, 

483 
Loewenberg's ozena diplococcus, 70 
Lofner's solution in diphtheria, 541 
Logan's operation for chronic epipharyngeal 

periadenitis, 436 
Low tracheotomy, 789 
Ludwig's angina, 558 
synonyms, 558 ' 
Lumpy jaw, 600 
Lungs in production of voice, 737 

size of, controlling volume, timbre, and tone 
of voice, 737 
Lupoid ulcers, nasal, 188 



828 



INDEX. 



Lupus exedens, 173 
nasal, 170 

age occurring, 170 

and fibroma, differentiation , 173 

and malignant growths, differentiation, 
179 

and polyps, differentiation, 179 

and syphilis, differentiation, 179 

and tuberculosis, differentiation, 179 

cells in, 171 

complications, 173 

crusts in, 172 

definition, 170 

deformities of nose from, 172 

degenerative changes in, 171 

diagnosis, 173 

discharge in, 172 

erysipelas in, 173 

etiology, 170 

predisposing, 170 

fibrous cicatrix in, 172 

formation of nodules in, 170 

glandular involvement in, 170 

itching in, 172 

nasal obstruction in, 172 

necrosis in, 170 

nodules in, 172 

pathology, 170 

prognosis, 173 

scar- formation after, 172 

sex in, 170 

symptoms, 172 

treatment, 173 

constitutional, 173 
local, 173 

tubercle bacilli in, 171 

ulceration in, 170 

vascular supply in, 171 
non-ex edens, 172 
of larynx and syphilis, differentiation, 700 

and tuberculosis, differentiation, 707 
of nasopharynx, 590. See also Pharynx, 

lupus of. 
of pharynx, 590. See also Pharynx, lupus 

of. 
of tonsils, 590. See also Pharynx, lupus of. 
stenosis of larynx in, 631 
prognosis, 631 
treatment, 631 
Luschka's tonsil, 26, 457 

Lymphatic glands, submaxillary, enlarge- 
ment of, in primary stage of acquired nasal 
syphilis, 150 
Lymphosarcoma of pharynx, 282 
of tonsil, 283 



MacCoy's acid-applicator, 709 
Mackenzie's condenser and reflecting mirror, 
33 
laryngeal dilator, 631 
electrode, 771 
forceps, 694 
throat forceps, 694 
Maggots in nose, 228 
Magnesia, calcined, in papilloma of larynx in 

children, 238 
Magnet for removal of metallic foreign bodies, 

715 
Makuen on deaf-mutism, 742, 744 
Makuen's definition of speech, 734 
of voice, 734 
method of treating stammering, 756 
physiologic alphabet, 757 
set of tonsil instruments, 494 
Malaria, acute laryngitis in, 641 
Malformations of larynx, 628 

of nasal space as cause of nasal tubercu- 
losis, 166 
structures predisposing to hay fever, 199 
of pharynx, 519 
of septum, 292 



Malformations, rudimentary, of uvula, 443 
Maliasmus, 174 

Mallein in glanders of pharynx, 600 
Mallet, 308 
Malleus, 174 
humidus, 174 
of pharynx, 597 
Mathieu's throat-forceps, 254 
Maxillary sinus, 358. See also Antrum of 
Highmore. 
sinuses, 22. See also Sinuses, accessory, 

maxillary. 
sinusitis, eye signs, 419 
Mayer's pharyngeal curet, 589 
McAuliffe's adenotome, 470 
McCormick's method of treating stammering, 

755 
Measles, acute laryngitis in, 639 
prognosis, 640 
_ treatment, 640 
simple rhinitis in, 82 
nasal ulcers in, 190 
pharynx in, 555 
treatment, 555 
Meatus, definition and position, 20 
fourth, 21 
inferior, 21, 44 
middle, 21, 44 
superior, 21, 44 
Membrana tympani, retraction of, in chronic 

epipharyngeal periadenitis, 433 
Membranous angina, 530 
croup, 661 

idiopathic, 661 
inflammation, non-infectious, in acute phar- 
yngitis, 522 
of faucial tonsil, 485. See also Tonsillitis, 

membranous. 
of mucous membrane, 64 
laryngitis, 661. See also Laryngitis, mem- 
branous. 
pharyngitis, 529 
simple, 529 
varieties, 529 
rhinitis, 97 
sore throat, 605 

tonsillitis, 485. See also Tonsillitis, mem- 
branous. 
Memory, relation of odor perception to, 29 
Meningitis after sinusitis, 352 

in confined suppuration of frontal sinus, 408 
in suppurating ethmoiditis, 389, 390 
suppurative, in empyema of sphenoidal 
sinus, 397 
Menopause, varices of lingual tonsil in, 517 
Mental condition in chronic purulent empyema 
of frontal sinus, 405 
in confined suppuration of frontal sinus, 

406 
in pharyngeal tonsil, 462 
derangement in suppurating ethmoiditis, 

389 
development, defects of speech affecting, 

750 
dulness in follicular pharyngitis, 570 
Mercury after salvarsan treatment of syphilis, 

157 
Mermod's intra] aryngeal mirror, 627 
Metastasis, pyemic, in typhoid fever as cause 

of chondritis of larynx, 669 
Mezzo-soprano voice, 734 
Miasmatic epiglottis, 641 
Micrococcus, 70 
catarrhalis, 71 
pneumoniae, 70 
Migraine, neuroses, reflex nasal, 213 
Mikulicz intranasal opening into maxillary 

sinus, 375 
Milbury's bone-forceps, 111 
Miliary tubercles in nasal tuberculosis, 167 

symptoms, 168 
Miller's asthma, 644 



INDEX. 



829 



Mirror, Mermod's, 627 

method of holding, in posterior rhinoscopy, 

38 
position of, in examination of larynx, 625 
size of, in examination of larynx, 625 
Mirrors for illumination, 31 

reflecting, 31 
Mixed tumors of respiratory tract, 286 
Mogilalia, 749 
Mogiphonia, 760 
Alosher's forceps, 719 

tracheoscope for adults, 719 
Moth-eaten appearance of mucous membrane 

in tuberculosis of pharynx, 587 
Moure's operation for septal deviation, 323 
Mouth, acoustics of, relation, to voice, 738 
inspection of, in diphtheria, 534 
reflex nasal neuroses of, 208 
Mouth-breathing, 52 

effect on general health, 52 

in children, 52 
in hyperplastic rhinitis, 118 
in hypertrophic tonsillitis, 490 
in pharyngeal tonsil, 462 
occupation as cause, 53 
palatal arch altered in children by, 52 
Mouth-gag, Ferguson's, 719 

Stubb's, 468 
Mucocele, 287, 288 

of antrum of Highmore, 362, 382. See also 

Antrum of Highmore, mucocele of. 
of ethmoidal sinuses, 392 
diagnosis, 392 
symptoms, 392 
treatment, 393 
of frontal sinus, 413 

degenerative changes in, 413 
diagnosis, 413 
etiology, 413 
pain in, 413 
prognosis, 413 
symptoms, 413 
thinning of walls in, 413 
treatment, 413 
of larvnx, 265 
diagnosis, 266 
dyspnea in, 266 
pathology, 266 
prognosis, 266 
symptoms, 266 
treatment, 266 
voice in, 266 
of nasopharynx, 265 
of respiratory tract, 265 
diagnosis, 265 
etiology, 265 
pathology, 265 
prognosis, 265 
symptoms, 265 
synonyms, 265 
treatment, 265 
of sphenoidal sinuses, 399 
Mucoid degeneration and nasal polypus, dif- 
ferentiation, 260 
Mucous croup, 649 

glands, amyloid degeneration, in keratosis 

of pharynx, 610 
membrane, actinomj-eosis of, 67 

areas of hvperesthesia in, in hav fever, 

202 
atrophy of, in atrophic rhinitis secondary 

to lesion elsewhere, 137 
basement membrane of, 60 
connective tissue in, 59 
varying thickness of, 60 
character of, in anemia, 51 
coagulation-necrosis of, 65 
color of. in hyperplastic rhinitis, 118 
congestion of, climate as cause of, 114 
exhaustion as cause of, 114, 115 
gastric diseases as cause of, 114 
in chronic constipation, 51 



Mucous membrane, congestion of, in intestinal 
irritation, 51 

lesions of respiratory tract as cause of, 
114 

sexual excitement as cause of, 115 

viscera causing alteration in, 51 
effect of disease on, 51 

of excessive alkalinitv of secretion on, 
58 
engorgement of, in hyperplastic rhinitis, 

118 
function of, 60 
general consideration of, 51 
glanders of, 67 
granuloma of, 66 

infectious, 66 
hyperplasia of, in reflex nasal asthma, 

211" 
impairment of sensibility, in hyperplas- 
tic rhinitis, 118 
in acute abscess of septum, 336 

catarrhal laryngitis, 635 

nasopharyngitis, 422, 423 

pharyngitis, 521 
color of, 522 

rheumatic pharyngitis, 581 
in anemia of pharynx, 615 
in animate foreign bodies in anterior 

nasal cavities, 229 
in atrophic pharyngitis, 575, 576 

rhinitis due to pre-existing lesion, 
132, 134 
pathological alterations, 130 
secondary to lesion elsewhere, 137 
in chronic catarrhal inflammation of 
frontal sinus, 401 

pharyngitis, 562, 563 

purulent inflammation of frontal sinus, 
405 

simple rhinitis, 109 
in epidemic influenza, 88 
in follicular pharyngitis, 566, 568, 570 
in glanders of pharynx, 597 
in hereditary nasaf syphilis, 163 
in herpes of pharynx, 605 
in hyperesthetic rhinitis, 195, 196, 203 
in hyperplastic rhinitis, 117 
in inanimate foreign bodies in anterior 

nasal cavities, 226, 227 
in infective pharyngitis, 527 
in lupus of pharynx, 590 591 
in nasal glanders, 175 

hydrorrhea, 142 

leprosy, 178 
in purulent rhinitis, 140 
in sarcoma of nose, 279 
in secondary stage of acquired nasal syph- 
ilis, 150 
in tertiary period of acquired nasal syph- 
ilis, 148, 151 

syphilis of pharynx, 595 
in tuberculosis of larynx, 706 
increase of connective-tissue elements of, 

in hyperplastic rhinitis, 116 
increased exudate from, in constitutional 

diseases, 51 
inflammation of, 60 

catarrhal, 62 
acute, 62 
chronic, 63 

clinical phenomena of, 60 

croupous, 64 

diphtheritic, 64 

extravascular stage of, 61 

fibrinoplastic, 64 

first stage of, 61 

gangrenous, 65 

hemorrhagic, 65 

membranous, 64 

microscopical phenomena of, 60 

pseudomembranous, 64 

pustular, 66 



830 



INDEX. 



Mucous membrane, inflammation of, second 
stage of, 61 
specific, 66 
suppurative, 66 
terminative stage, 61 
third stage of, 61 
influence of slit-like nostril on, 52 

of systemic diseases on, 51 
layers of, 59 
leprosy of, 68 
moth-eaten appearance, in tuberculosis 

of pharynx, 587 
of accessory sinuses, 22, 349 
color, 23 

in anemia, 23 
in plethora, 23 
destruction, 349 
structure, 23 
of anterior nasal cavities, 22 

color, 23 
of pharvnx or larynx, effect of climate on, 

580 
of septum, 289 

swollen, in hyperplastic rhinitis, 118 
oversensitive, as cause of acute naso- 
pharyngitis, 422 
pallor of, in hay fever, 201 
pathological changes, 51 
relation to general medicine, 51 
rhinoscleroma of, 68 

sensitive areas of, in reflex nasal asthma, 
211 
predisposing to taking cold, 73 
specific processes of, 66 
structure of, 59 
submucosa, character of, 60 
swelling of, in intumescent rhinitis, 115 
syphilis of, 66 
thickened, after epidemic influenza, 89 

in hyperplastic rhinitis, 118 
tuberculosis of, 67 
turgescence of, at puberty, 114 
patch as symptom of syphilis of larynx, 697 
in hereditary nasal syphilis, 163 
in nose, 188 

in secondary stage of acquired nasal 
syphilis, 117, 150 
syphilis of pharynx, 595 
polypi, 265 
Mucus, excess" of, in intumescent rhinitis, 115 
Mulberry form of hyperplastic rhinitis, 119 
Multinebulizer, six-flask Globe, 48 
Muscle, crico-arytenoid, paralysis of, in lar- 
yngismus stridulus, 645 
Muscles, abdominal, in anesthesia, 467 
eye-, paralysis of, from sinusitis, 351 
improper use of, as cause of chronic phar- 
yngitis, 561 
of hearing in chronic epipharyngeal peri- 
adenitis, 433 
of larynx, paralysis of, 774 
prognosis, 776 
treatment, 776 
Muscular insufficiency of palate, 449 
Musical ear, 737, 739, 742 
Mutation of voice, 735, 749 
Myasis narium, 228 
Mycosis of fauces involving uvula, 448 
of faucial tonsil, 512 
diagnosis, 512 
etiology, 512 

Leptothrix buccalis as cause, 512 
prognosis, 512 
teeth as cause, 512 
_ treatment, 512 
of lingual tonsil, 516 
etiology, 516 

Leptothrix buccalis, 516 
treatment, 516 
ulceration in, 516 
of uvula, 448 
Myles' antrum-curets, 363 



Myles' curved trocar, 374 
Myofibroma, nasal, 261 
Myxocarcinoma of respiratory tract, 286 

as nidus for development of sarcoma, 

262 
diagnosis, 262 
etiology, 261 
pathology, 262 
prognosis, 262 
symptoms, 262 
treatment, 262 
Myxoma of antrum of Highmore, 383 
of ethmoidal sinuses, 393 
of frontal sinus, 415 

of respiratory tract, 256. See also Poly- 
pus, nasal. 
of sphenoidal sinuses, 398 
Myxosarcoma, 261 



Narcotics as cause of chronic pharyngitis, 560 
Nares, adenoma of, 238 
fibroma of, 248 

foreign bodies in, ulcers due to, 186 
lipoma of, 253 
occlusion of, causes, 292 
osteoma of, 254. See also Osteoma of nares. 
papilloma of, 234 
treatment, 234 
posterior, occlusion of, causes, 291 
slit-like, in catarrhal diathesis, 52 
Nasal actinomycosis, 179 
ate, collapse of, 327 
treatment, 327 
angiofibromyxoma, 258 
applicator, 47 
artery of septum, 290 
bacteria, 71 

relation of, to disease, 68 
blennorrhea, acute, 74 
breathing, importance of, 52, 114 
in early childhood, 297 
in relation to hearing, 114 
in hyperplastic rhinitis, 118 
results of failure of, 52 
bridge, flattened, in hereditary nasal syph- 
ilis, 163 
calculi, 224. See also Rhinoliths. 
cartilages, depression of, 338 
etiology, 338 
Roe's operation, 341 
treatment, 339 
White's operation, 339 
catarrh, acute, 74 
atrophic, 125 
chronic, 107 
dry, 125 

hypertrophic, 116 
purulent, 140 
simple chronic, 107 
cavities, accessory, physiology of, 29 
anatomy, 17, 18 
angioma of, 240. See also Angioma of 

nasal passage. 
anterior, acute inflammatory disease of, 
72 
anatomy, 17, 18 

chronic inflammatory diseases, 107 
color, 43 
diseases, 72, 107, 289, 348 

chronic inflammatory, 107 
examination of, by incandescent elec- 
tric bulb, 41 
foreign bodies in, 224. See also Foreign 

bodies in anterior nasal cavities. 
inflammatory diseases, 184 
mucous membrane of, 22 

color, 22 
non-inflammatory diseases of, 217 
normal appearance of, 43 
arteries of, 24 
blood-supply of, 24 



INDEX. 



831 



Nasal cavities, carcinoma of, 267. See also 
Carcinoma of nasal passage. 
chondroma of, 243. See also Chondroma 

of nasal passage. 
diseases of, predisposing to hyperes- 

thetic rhinitis, 199 
fibroma of, 247. See also Fibroma of 

nasal cavities. 
function of, 27 
glioma of, 286 

malformations of, as cause of acute 
simple rhinitis, 75 
predisposing to hay fever, 199 
mucous membrane of, glands in, 24 
nerves of, 25, fig. 13 
olfactory function of, 27 
osteoma of, and chondroma, differentia- 
tion, 244 
papilloma of, 234 
symptoms, 234 
treatment, 234 
phonation function of, 28 
physiology, 17, 27 

posterior, examination of, by incandescent 
electric bulb, 41 
normal appearance of, 43 
protective function, 28 
relation of, to hearing, 28 

to taste, 28 
respiratory function of, 27 
sarcoma of, 278. See also Sarcoma of 

nose. 
secretion in, in hyperplastic rhinitis, 119 
vestibule, 19 
anatomy, 19 
framework, 19 
chancre, 188 
concretions, 224 

congestion predisposing to taking cold, 74 
cough, 208, 634 
deformities, external, correction of, 338 

Carter's bone transplantation opera- 
tion for, 345 
bridge-splint operation for, 341 
from nasal syphilis, 151 

paraffin injections in, 154 
Gersunv's paraffin method for correcting, 

154 
paraffin injections for, 154 
dilator, Sinexon's, 302 
diphtheria, 102, 535 
acute, 535 

and croupous rhinitis, differentiation, 99 
chroDic, 535 
discharge in acute simple rhinitis, 77 
disease from irregularities in formation of 

accessory sinuses, 351 
douche, Bermingham, 47 

caution in using, 46 
duct, obstruction of, in hyperplastic rhinitis, 

121 
epithelioma and rhinoscleroma, differentia- 
tion, 181 
examination, rules for, 39 
fibroma and lupus, differentiation, 173 
fossae, involvement of, in hyperplastic 

rhinitis, 119 
furunculosis, 183. See also Furunculosis, 

nasal. 
glanders, 174. See also Glanders, nasal. 
growths as cause of cough, 633 
hydrorrhea, 141, 194. See also Hydrorrhea, 

nasal. 
irregularities predisposing to taking cold, 

73 
keloid and rhinoscleroma, differentaition, 

181 
leprosy, 177. See also Leprosy, nasal. 
lesions from lesions of accessory sinuses, 51 
lupus, 170. See also Lupus, nasal. 
malignant growths and lupus, differentia- 
tion, 173 



Nasal malignant growths and tuberculosis, 
differentiation, 169 
membrane, hyperesthesia in, in hay fever, 

202 
mucosa, 22 
myxofibroma, 261. See also Myxofibroma, 

nasal. 
nerve, neuralgia of, in atrophic rhinitis 

secondary to lesion elsewhere, 139 
neuroses, 191. See also Neuroses, nasal. 
reflex, 193. See also Neuroses, reflex 
nasal. 
obstruction as cause of atrophic pharyn- 
gitis, 574 
of chronic nasopharyngitis, 427 

pharyngitis, 562 
of reflex nasal asthma, 210 
blood-changes in. 53 
causes of, 290-292 
extranasa), 291, 292 
intranasal, 290, 292 
due to extension of growths from neigh- 
boring cavities, 291 
effects, 291 
eye-lesions from, 417 
from pharyngeal tonsil. 457 
in angioma of nasal passage, 241 
in atrophic rhinitis secondary to lesion 

elsewhere, 138 
in chondroma of nasal passage, 244 
in chronic pharyngitis, 564 
in confined suppuration of antrum of 

Highmore, 369 
in fibroma of nasal passage, 248 
in fibromyxoma of nasopharynx, 264 
in hereditary nasal syphilis, 163 
in hyperplastic rhinitis, 118 
in hypertrophic tonsillitis, 489 
in nasal lupus, 172 
polypus, 259 
tuberculosis, 168 
in osteoma of nares, 255 
in primary stage of acquired nasal syph- 
ilis, 149 
in sarcoma of nasopharynx, 280 

of nose, 279 
in synechia, 326 
predisposing to taking cold, 73 
signs, 291 
svmptoms, 291 
phthisis, 166 

polypus, 256. See also Polypus, nasal. 
fibrous, 261. See also Myxofibroma. 
probe, 47 
saw, Kyle's, 121 
space, malformation of, as cause of nasal 

tuberculosis, 166 
speculum, Allen's, 36 
bivalve, 37 
Gleason's, 38 
self-retaining, 308 
splint, Carter's, 342 
syphilis, 145 
acquired, 145 

bacteriology, 145 

Colles' law of immunity in, 146 

complications, 152 

definition, 145 

diagnosis, 152 

etiology, 145 

nasal deformities from, 151 

paraffin injections in, 154 
pathology, 146 
primary stage, diagnosis, 152 

enlargement of submaxillary lym- 
phatic glands in, 150 
indolent bubo in, 150 
occlusion of nasal space in, 149 
papule in, 149 
pathology, 146 
symptoms, 149 

of primary sore in, 149 ■ 



832 



INDEX. 



Nasal syphilis, acquired, primary stage, treat- 
ment, 152 
Wassermann reaction in, 152 
Profeta's law of immunity, 146 
prognosis, 152 

secondary stage, anorexia in, 150 
coryza in, 150 

pathology, 147 
diagnosis, 152 
difficult respiration in, 150 
discharge in, 150 
eruption in, 150 
eruptions in, 150 
headache in, 150 
impairment of hearing in, 150 
of smell in, 150 
of taste in, 150 
lacrimation in, 150 
mucous membrane in, 150 

patch in, 147, 150 
pathology, 147 
photophobia in, 150 
pus in, 147 
sneezing in, 150 
symptoms, 150 
treatment, 153 
ulceration in, 147 
tertiary period of, areas of fibroid de- 
generation in, 152 
blood-vessels in, 148 
caries in, 149 
cartilage in, 149 
diagnosis, 152 

diminished discharge in, 151 
gumma in, 148 
loss of smell in, 151 

of mucous membrane in, 148 
nasal obstruction in, 151 
necrosis in, 149, 151 
odor in, 151 
pain in, 151 
pathology, 148 
reminders in, 151 
structural changes in, 151 
swellings in, 151 
symptoms, 150 
treatment, 153 
ulceration in, 151 
treatment, 152 
and leprosy, differentiation, 179 
and lupus, differentiation, 173 
and rhinoscleroma, differentiation, 181 
and tuberculosis, differentiation, 169 
definition, 145 
germ-inheritance in, 162 
hereditary, 162 
definition, 162 
diagnosis, 164 
discharge in, 163, 164 
early, 162 

diagnosis, 164 
pathology, 162 
prognosis, 164 
symptoms, 163 

Wassermann reaction in diagnosis of, 
164 
enlargement of glands in, 163 
eruptions in, 163 
etiology, 162 

parental transmission, 162 
facial deformity in, 164 
flattened nasal bridge in, 163 
gumma in, 163 
Hutchinson's teeth in, 163 
late, 162 

diagnosis, 164 
pathology, 162 
prognosis, 164 
symptoms, 164 
mucous membrane in, 163 

patches in, 163 
nasal obstruction in, 163 



Nasal syphilis, hereditary, necrosis in, 163, 
164 

noisy breathing in, 163 

pathology, 162 

prognosis, 164 

rhinitis in, 163 

secondary type, 162 

skin-lesions in, 163 

spasms in, 163 

symptoms, 164 

synonyms, 162 

tertiary type, 162 

therapeutic test in, 163 

treatment, 165 

voice in, 163 
parental transmission of, 162 
sperm-inheritance, 162 
synonyms, 145 
tonsil, 456 

tube, Kyle's long, 303 
in position, 303 

malleable, 299 
tuberculosis, 166 

and lupus differentiation, 173 

and malignant growths, differentiation, 

169 
and syphilis, differentiation, 169 
as secondary infection, 166 
blood-supply in, 167 
cells in, 167 
complications, 169 
constitutional condition in, 168 
contagion in, 166 
definition, 166 
diagnosis, 169 
etiology, 166 

exciting, 166 

predisposing, 166 
fibrous cicatrix in, 167 
glandular involvement in, 167 
liquefaction-necrosis in, 167 
malformation of nasal space as cause of, 

166 
miliary tubercles in, 167 

symptoms, 168 
nasal obstruction in, 168 
pathology, 166 
prognosis, 169 
swelling in, 167 
symptoms, 168 
synonyms, 166 
treatment, 169 
tubercular ulcers in, 167 
symptoms, 168 
ulcers, 184. See also Ulcers, nasal. 
Nasopharyngeal bursitis, chronic, 432 
Nasopharyngitis, acute, 411 

after infectious diseases, 30 

age in, 422 

catarrhal ulcers in, 423 

definition, 421 

diagnosis, 423 

dryness in, 422, 423 

etiology, 421 

exciting, 422 

predisposing, 421 
hemorrhage in, 423 
impairment of hearing in, 423 
irregularities of climate as cause, 422 
mucous membrane in, 422, 423 
onset, 422 
oversensitive mucous membrane as cause, 

422 
pain in, 423 
pathology, 422 
prognosis, 423 
secretion in, 423 
symptoms, 422 
synonyms, 421 
treatment, 423 
voice in, 423 
atrophic, 437 



INDEX. 



833 



Nasopharyngitis, atrophic, diagnosis, 439 

involvement of Eustachian tube in, 438 

narrow nasopharyngeal space in, 438 

pathology, 438 

prognosis, 439 

secretion in, 438 

treatment, 439 
chronic, 425 

abnormalities of nasopharvnx as cause, 
426 

after infectious diseases, 426 

age in, 426 

complications, 430 

cough in, 429 

definition, 425 

diagnosis, 430 

dryness in, 429 

dyspepsia as cause, 426 

ear in, 429 

etiology, 426 
exciting, 426 
predisposing, 426 

gastric disturbances in, 429, 430 

headache in, 429 

heredity in, 426 

impairment of hearing in, 429 

inflammatory ccmditions in adjacent 
structures as cause, 426 

involvement of Eustachian tube in, 430 

irregularities of climate as cause of, 427 

nasal obstruction as cause, 427 

pain in, 429 

pathology, 428 

pharyngeal bursa in etiology of, 426 

postnasal space in, 430 

prognosis, 430 

secretion in, 429 

swelling and relaxation of soft palate in, 
430 
of uvula in, 430 

symptoms, 429 

synonyms, 425 

tinnitus aurium in, 429 

torpid liver as cause of, 426 

treatment, 430 

voice in, 426, 429 
hyperplastic, 440 

etiology, 440 

involvement of Eustachian tube in, 
440 

symptoms, 440 

treatment, 440 
in hyperplastic rhinitis, 121 
Nasopharyngoscope, Holmes', 42 
Nasopharynx, abnormalities of, as cause of 

chronic nasopharyngitis, 426 
actinomycosis of, 600. See also Pharynx, 

actinomycosis of. 
adenoma of, 238 

anatomy, 25 
arterial supply, 27 
carcinoma of, 269. See also Carcinoma 

of nasopharynx. 
catarrh of, acute, 421 

chronic, 425 
chondroma of, 244 
closure of, by adhesion of soft palate to 

pharynx, 450 
diseases of, 421 

producing alterations in sound-percep- 
tion apparatus, 741 
examination of, in diagnosis of diphtheria, 

537 
fibroma of, 249. See also Fibroma of naso- 
pharynx. 
fibromyxoma of, 263. See also Fibromyxoma 

of nasopharynx. 
glanders of, 597. See also Pharynx, glanders 

°f- 

in atrophic rhinitis due to pre-existing 

lesion, 135 
infectious granuloma of, 586 

53 



Nasopharynx, inflammations of, specific, 442 
involvement of, in atrophic pharyngitis, 575 
irritation in, as cause of follicular phar- 
yngitis, 567 
isthmus of, 26 

keratosis of, 608. See also Pharynx, kera- 
tosis of. 
lipoma of, 253 

lupus of, 590. See also Pharynx, lupus of. 
mucocele of, 265 
nerves of, 27 
neuroses of, 442 
aural, 442 

convulsive seizures in, 442 
laryngismus stridulus, 442 
stammering in, 442 
obstruction in, causes, 291 
papilloma of, 234 
symptoms, 234 
treatment, 235 
sarcoma of, 280. See also Sarcoma of naso- 
pharynx. 
shape of, in pharyngeal tonsil, 464 
syphilis of, 592. See also Pharynx, syph- 
ilis of. 
tuberculosis of, 586. See also Pharynx, 
tuberculosis of. 
Nebulizer, 47 
Neck, cellulitis of, 558 

emphysema of, in foreign bodies in larvnx, 

728 
glands of, involvement of, in sarcoma of 
tonsils, 281 
Necrosis, bony, from diseases of accessory 
sinuses, 351 
coagulation-, in membranous tonsillitis, 486 
in tonsillar abscess, 483 
of mucous membrane, 65 
in acquired tertian,' nasal syphilis, 151 
in acute purulent empyema of frontal sinus, 

404 
in confined suppuration of frontal sinus, 408 
in hereditary nasal syphilis, 162, 164 
in nasal glanders, 175 

lupus, 170 
in tertiarv form of acquired nasal syphilis, 

148, 149 
liquefaction-, in cryptic tonsillitis, 475 
in infective pharyngitis, 527 
in nasal glanders, 175 
leprosy, 178 
tuberculosis, 167 
of septum, 328 
Necrotic tissue, discharge of, in tertiary syph- 
ilis of pharynx, 596 
Needles, Delavan's, 242 

Negative air pressure in accessory sinus dis- 
ease, 378 
Neoplasms. See Tumors. 
Neosalvarsan in syphilis, 156 
intravenous injection, 159 
apparatus for, 159 
Nerve, recurrent laryngeal, 771 
Nerve-filaments in nasal polypus, 259 
Nerve-supply of nose, 290 
Nerves, laryngeal, superior, paralysis of, 769 
diagnosis, 769 
prognosis, 769 
symptoms, 769 
treatment, 769 
of nasal cavities, 25, fig. 13 
of nasopharynx, 27 
Nervous complications of atrophic rhinitis due 
to pre-existing local lesion, 135 
cough, 634, 759 
diseases, cough in, 633 

habit predisposing to hvperesthetic rhini- 
tis, 194, 195, 198 
phenomena as cause of chronic pharyn- 
gitis, 560 
of follicular pharyngitis, 567 
system in reflex nasal asthma, 211 



834 



INDEX. 



Neuralgia, facial, dependent on nasal lesion, 53 
on sinus-lesion, 53 
in diseases of accessory sinuses, 354 
of larynx, 762 

treatment, 763 
of nasal nerve in atrophic rhinitis second- 
ary to lesion elsewhere, 139 
of pharynx, 617 

treatment, 617 
of soft palate, 453 
of sphenopalatine ganglion, 357 

treatment, 357 
reflex nasal, 213 
supra-orbital, reflex nasal, 213 
Neuralgic pains in diseases of accessory 

sinuses, 354 
Neurasthenia, epistaxis in, 217 
Neuroparalytic ulcers, nasal, 186 

treatment, 186 
Neuro-recurrences after salvarsan in syphilis, 

161 
Neuroses in chronic simple rhinitis, 108 
in diphtheria, 539 
nasal, 191 

of olfaction, 191 
anosmia, 192 
hyperosmia, 192 
parosmia, 191 
of larynx, 759 
of nasopharynx, 442 
aural, 442 

convulsive seizures in, 442 
laryngismus stridulus, 442 
stammering in, 442 
of pharynx, 615 

of motion, 617 
of soft palate, 453. See also Palate, soft, 

neuroses of. 
reflex, from hypertrophic tonsillitis, 490 
in nasal polypus, 259 
nasal, 193 
acne, 214 
aphonia, 209 
aprosexia, 214 
asthma, 210. See also Asthma, reflex 

nasal. 
chorea, 213 
cough, 208 
definition, 193 
epilepsy, 213 
erythema, 214 
headache, congestive, 213 
hydrorrhea, 194 
idiopathic rhinorrhea, 194 
lacrimation, 213 
migraine, 213 
neuralgia, 213 

supra-orbital, 213 
of ear, 212 
of eye, 213 
of heart, 214 
of larynx, 209 
of mouth, 208 
of pharynx, 208 
of sexual organs, 215 
of stomach, 214 

outside of respiratory tract, 212 
respiratory, 193 
rhinitis, hyperesthetic, 194. See also 

Rhinitis, hyperesthetic. 
sneezing, 193 
tic douloureux, 213 
treatment, 215 
general, 215 
local, 215 
urticaria, 214 
Newborn, purulent rhinitis in, etiology, 140 
Night-cough, 633 
Nipple, Paget's disease of, and keratosis of 

pharynx, microscopic resemblance, 611 
Nitrous oxid and oxygen anesthesia, 466 
Nodules, vocal, 691 



Nose and eye, communication between, by 
lacrimal duct, 416 
bacteria in, 71 
cartilage of, lateral, 19 
deformities of, from nasal lupus, 172 
diseases of, relation of, to eye, 416 

vaccine therapy in, 93 
foreign bodies in, as cause of acute simple 

rhinitis, 76 
inflammation of, spread of, through lacri- 
mal duct, 417 
injuries to, reflex nasal asthma after, 210 
maggots in, 228 
red, 215 

saddle-back, White's operation for, 339 
skin of, in in tumescent rhinitis, 115 
snub-, in atrophic rhinitis due to pre-existing 

lesion, 134 
stuffiness in, in acute simple rhinitis, 77 
Nose-bleed, 217. See also Epistaxis. 
Nostril. See Nares. 

Nutrition in spasm of larynx in children, 647 
Nystagmus, laryngeal, 766 
of pharynx, 617 



Obstruction in nasopharynx, causes, 291 

laryngeal, spasmodic, 767 

nasal. See Nasal obstruction. 

of anterior nares, causes, 291 

of lacrimal canal in hyperplastic rhinitis, 
119 

of nasal duct in hyperplastic rhinitis, 121 

of posterior nares, causes, 291 

of sinus outlets in hyperplastic rhinitis, 121 
Obstructive rhinitis, 116 

Occupation as cause of follicular pharyngitis, 
567 
of mouth-breathing, 53 

predisposing to epistaxis, 218 
to taking cold, 74 

rhinitis, 76 
Occupation-pharyngitis, 549. See also Phar- 
yngitis, occupation-. 
Occupation-rhinitis, 102. See also Rhinitis, 

occupation-. 
Ocular diphtheria, treatment, 545 

signs of diseases of accessory sinuses, 419 
Odor in acquired tertiary nasal syphilis, 151 

in actinomycosis of pharynx, 601 

in atrophic pharyngitis, 576 

rhinitis due to pre-existing lesion, 132, 133 

in cancer of larynx, 276 

in diphtheria, 534 

in gangrenous pharyngitis, 549 

in purulent rhinitis, 140 

in rheumatic tonsillitis, 478 

in sarcoma of tonsil, 283 

in tertiary syphilis of pharynx, 596 

in tonsillar abscess, 482 

in tuberculosis of pharynx, 588 

of saliva, 56 

perception of, relation of, to memory, 29 
O'Dwyer's instruments for intubation, 778 
Office, stool and chair for, 34 

work, instruments for, 45 
cleanliness, 49 
sterilization of, 49 
Ogston-Luc operation for confined suppura- 
tion of frontal sinus, 409 
Olfaction, neuroses of, 191 
Olfactorial cells of Schultze, 24 
Olfactory function of nasal cavities, 27 

stimulus, oversensitiveness to, 192 
Opisthotonos in spasm of larynx in children, 

647 
Opsonic index, 94 

strength of blood, 94 
Opsonin treatment, 93 
Opsonins, 93 

in blood, 94 

nature of, 94 



INDEX. 



835 



Orbital abscess in empyema of antrum of High- 
more, 373 
in suppurating ethmoiditis, 390 
secondary to disease of accessory sinuses, 
351 
cellulitis from disease of accessory sinuses, 
351 
Oropharynx, 17, fig. 1 
Ossification in chondroma of nasal passage, 

244 
Osteoma of antrum of Highmore, 383 
of ethmoidal sinuses, 393 
of frontal sinus, 415 
of nares, 254 

and chondroma, differentiation, 244 
cancellous, 254 
diagnosis, 255 
discharge in, 255 
eburnated, 254 
nasal obstruction in, 255 
pain in, 255 
pathology, 254 
prognosis, 255 
symptoms, 255 
treatment, 255 
of respiratory tract, 254 
of sphenoidal sinuses, 398 
Osteomyelitis in acute purulent empyema of 

frontal sinus, 404 
Ostia ethmoidalia, 21 
Ostitis in acute purulent empyema of frontal 

sinus, 404 
Ostium maxillare, 22 
accessorius, 22 . 

closure of, as cause of acute catarrhal 
inflammation of antrum of Highmore, 
359 
Ostrom's biting-forceps, 375 
Otalgia in tuberculosis of pharynx, 587 
Otitis media, Bacillus segmentosus in produc- 
tion of, 71 
in acute superficial tonsillitis, 473 
in cryptic tonsillitis, 476 
Ozaena larvngis, 685 
Ozena, 123, 125 
as symptom, 123 
bacteriology of, 124 
constitutional, 125 
definition of term, 123 
diplococcus of Loewenberg in, 70 
diseases occurring in, 123 
due to combination of causes, 124 
hypertrophic, 116 
idiopathic, 125 
in atrophic rhinitis, 129 
lactic-acid bacteria in treatment of, 136 
laryngotracheal, 686 
limitation of, 123 
loss of smell in, 124 
of antrum of Highmore, 364 
diagnosis, 364 
etiology, 364 
prognosis, 364 
treatment, 364 
scrofulous, 85 
simple, 125 
syphilitic, 145 
tuberculosis in, 125 
variation in manifestations of, 123 



Pachydermia diffusa, 236 

laryngis, 691 

verrucosa, 236 
Pachymeningitis in confined suppuration of 

frontal sinus, 409 
Paget's disease of nipple and keratosis of 

pharynx, microscopic resemblance, 611 
Pain in acquired stenosis of larynx, 630 
tertiary nasal syphilis, 151 

in actinomycosis of pharynx, 601 

in acute abscess of septum, 336 



Pain in acute catarrhal inflammation of an- 
trum of Highmore, 360 
of frontal sinus, 400 

glanders of pharynx, 598 

nasopharyngitis, 423 

pharyngitis, 523 

phlegmonous inflammation of lingual ton- 
sil, 515 

purulent inflammation of antrum of High- 
more, 365 
of frontal sinus, 403 

rheumatic pharyngitis, 581, 582 

superficial tonsillitis, 472 
in angina ulcerosa benigna, 559 
in atrophic rhinitis due to pre-existing 

lesion, 133 
in cancer of larynx, 276 

of nasopharynx, 269 

of nose, 268 

of pharynx, 272 

of soft palate, 271 
in catarrhal inflammation of sphenoidal 

sinuses, 394 
in chondroma of nasal passage, 244 
in chronic catarrhal inflammation of an- 
trum of Highmore, 363 
of frontal sinus, 401 

glanders of pharynx, 599 

hyperplastic ethmoiditis, 386 

nasopharyngitis, 429 

pharyngitis, 564 

purulent inflammation of antrum of High- 
more, 368 
of frontal sinus, 405 
in confined suppuration of antrum of High- 
more, 369 
of frontal sinus, 406 
in cryptic tonsillitis, 475 
in diphtheria, 533 

as aid in diagnosis, 537 
in edematous laryngitis, 659 
in empyema of sphenoidal sinus, 395, 396 
in fibroma of nasal cavities, 248 
in follicular pharyngitis, 570 
in foreign bodies in nose, 230 
in gangrenous pharyngitis, 549 
in glandular pharyngitis lateralis, 552 
in hay fever, 203 
in hemorrhagic pharyngitis, 551 
in herpes of pharynx, 605 
in infective pharyngitis, 527 
in larynx, 762 

in membranous tonsillitis, 486 
in mucocele of antrum of Highmore, 382 

of frontal sinus, 413 
in nasal hydrorrhea, 143 
in osteoma of nares, 255 
in papilloma of larynx, 237 
in pemphigus of larynx, 691 
in primary syphilis of pharynx, 594 
in retropharyngeal abscess, 603 
in rheumatic laryngitis, 655 

tonsillitis, 479 
in sarcoma of larynx, 285 

of nasopharynx, 280 

of nose, 279 

of tonsil, 283 
in suppurating ethmoiditis, 389 
in suppurative laryngitis, 654 
in syphilis of larynx, 696 
in tertiary syphilis of pharynx, 596 
in tonsillar abscess, 483 
in tuberculosis of larynx, 705 

of pharynx, 587 
neuralgic," in diseases of accessory sinuses, 

354 
Palatal arch in children, altered, by mouth- 
breathing, 52 
Palate an important factor in development 

of speech, 747, 748 
congenital insufficiency of, 449 
treatment, 450 



836 



INDEX. 



Palate, hard, perforation of, 450 

loss of free movement of, in cancer of soft 

palate, 271 
soft, abnormalities of, 450 
from syphilis, 450 
abscess of, 447 
adhesions of, 450 

to pharynx, closure of nasopharynx 
from, 450 
alterations in normal sensitiveness, 453 
an important factor in enunciation, 747 
anesthesia of, 453 
carcinoma of, 270. See also Carcinoma of 

soft palate. 
diseases of, 443 
emphysema of, 450 

treatment, 450 
hyperesthesia of, 453 
neuroses of, 453 
neuralgia, 453 
paralysis, 453 

acute bulbar, 454 
apoplectiform bulbar, 454 
chronic bulbar, 454 
herpes, 455 
spasmodic contraction, 453 
non-inflammatory diseases, 450 
paresthesia of, 453 
perforation of, 450 

voice in, 450 
relaxation of, in pharyngeal tonsil, 463 
sarcoma of, 281 

swelling and relaxation of, in chronic naso- 
pharyngitis, 430 
tubulated epithelioma of, 270 
ulceration of, 450 
Palatine fold, adhesions to, in hypertrophic 

tonsillitis, 490 
Palliative tracheotomy, 797 
Palmer's frontal-sinus drill, 414 
Papillae, connective-tissue, in keratosis of 

pharynx, 609 
Papillary budding in keratosis of pharynx, 610 

edematous polypi, 257 
Papilloma of larynx, 235 

and epithelioma, differentiation, 237 
diagnosis, 237 
diffuse form, 236 
dyspnea in, 236 
hemorrhage in, 236, 237 
in children, calcined magnesia in, 238 
pain in, 237 
prognosis, 238 
superficial variety, 236 
symptoms, 236 
treatment, 238 
of nares, 234 

treatment, 234 
of nasal cavity, 234 
symptoms, 234 
treatment, 234 
of nasopharynx, 234 
symptoms, 234 
treatment, 235 
of pharynx, 235 
symptoms, 235 
treatment, 235 
of respiratory tract, 234 
Paraffin injections for nasal deformities, 154 
Quinlan's syringe for injection of, 155 
syringe, 155 
Paralysis as cause of defects of speech, 753 
bulbar, acute, of soft palate, 454 
apoplectiform, of soft palate, 454 
chronic, of soft palate, 454 
progressive, of pharynx, 618 
symptoms, 618 
diphtheritic, of pharynx, 618 
glossolabiolaryngeal, 618 
in diphtheria, treatment, 545 
labioglossopharyngeal, 454 
of arytenoids, 774 



Paralysis of crico-arytenoid muscle in laryn- 
gismus stridulus, 645 
of esophagus and spasm of pharynx, differ- 
entiation, 617 
of eye-muscles from sinusitis, 351 
of larynx, adductor, unilateral, 775 

and chronic laryngitis, differentiation, 681 
as cause of cough, 633 
bilateral abductor, 772. See also Larynx, 
paralysis of, bilateral abductor. 
adductor, 775 
central adductor, 774 
internal tensors, 775 

recurrent, 769. See also Laryngeal par- 
alysis, recurrent. 
unilateral abductor, 774 
prognosis, 774 
symptoms, 774 
treatment, 774 
of lateral crico-arytenoids, 775 
of muscles of larynx, 774 
prognosis, 776 
treatment, 776 
of pharynx, 617. See also Pharynx, par- 
alysis of. 
of soft palate, 453 
of superior laryngeal nerves, 769 
diagnosis, 769 
prognosis, 769 
symptoms, 769 
treatment, 769 
of thyro-arytenoids, 775 
of uvula, 453 
of vocal cords, 769 

in syphilis of larynx, 695 
Paraplegia, spastic, of larynx, 767 
Parenchymatous tonsillitis, 471, 474 
Parental transmission of nasal syphilis, 162 
Paresthesia of larynx, 761 
of pharynx, 616 
etiology, 616 
prognosis, 616 
treatment, 617 
of soft palate, 453 
Parosmia, 191 
Paroxysmal cough, 633 

Patch, mucous, as symptom of syphilis of lar- 
ynx, 697 
in hereditary nasal syphilis, 163 
in nose, 188 

in secondary stage of acquired nasal 
syphilis, 147, 150 
syphilis of pharynx, 595 
Peach cold, 194 
Peenash, 229 
Pemphigus of larynx, 690 
treatment, 691 
of pharynx, 604, 605 
Pent-up pus in antrum of Highmore, 368 
treatment, 373 
in frontal sinus, 405 
Perforation of septum, 331. See also Septum, 
perforation of. 
of soft palate, 450 
Perforator, Douglas' antrum, 374 _ 
Periadenitis, epipharyngeal, chronic, 431 
bacteria in, 434 
complications, 434, 435 
diagnosis, 434 
influenza in, 434 
Logan's operation for, 436 
pathology, 422 
prognosis, 434 

retraction of membrana tympani in, 433 
rhinitis in, 434 

sclerosis of middle ear in, 433 
symptoms, 436 
treatment, 436 
Perichondritis as cause of cough, 632 
of edematous laryngitis, 657 
of larynx, 668. See also Larynx, chondritis 
of. 



INDEX. 



837 



Perichondrium of septum, 289 
Perier's method of laryngectomy, 800 
Periodical hyperesthetic rhinitis, 194 
Periostitis in acute purulent empyema of 
frontal sinus, 404 
in confined suppuration of frontal sinus, 408 
Peripharyngeal phlegmon, 527 
Peritonsillar abscess, 482. See also Abscess, 
tonsillar. 
involvement in epidemic influenza, 88 
phlegmon, 482 
Pertussis, acute simple rhinitis in, 83 

and membranous laryngitis, differentiation, 
665 
Pfeiff er's bacillus in epidemic influenza, 87 
Pharyngeal bursa, 26 

as cause of chronic nasopharyngitis, 426 
suppuration of, empyema of sphenoidal 
sinus and, differentiation, 397 
recess, 26 
tonsil, 26, 44, 238, 456, 457 

abnormalities of development in, 462 

anemia in, 463 

choking in, 463 

climate as cause, 459 

cough in, 462 

deafness in, 462, 463 

desire to swallow in, 464 

diagnosis, 464 

earache in, 463 

elongation of uvula in, 463 

enlargement of faucial tonsil in, removal, 

469 
epistaxis in, 463 
etiology, 458 
eye-symptoms in, 464 
facial expression in, 462 
glandular enlargement in, 458 
headache in, 464 
hypertrophic tonsillitis associated with, 

490 
impairment of smell in, 464 

of taste in, 463 
in rhinitis, 459 
inherited tendency, 458 
involvement of Eustachian tube in, 463 
irritating materials as cause, 459 
mental condition in, 462 
mouth-breathing in, 462 
nasal obstruction from, 457 
pathology, 460 

edematous or cyanotic, 461 

four varieties 460 

hard variety, hyperplastic, 461 

inflammatory, 461 
microscopic appearance, 460 
soft variety, 460 
prognosis, 464 
recurrence, 458 

relaxation of soft palate in, 463 
shape of nasopharynx in, 464 
susceptibility to infectious diseases in, 463 
symptoms, 461 
synonyms, 457 
treatment, 464 

anesthesia in, 466 
voice in, 463 
xerostoma in, 463 
Pharyngitis, acute, 521 

as cause of chronic pharyngitis, 561 

of follicular pharyngitis, 567 
constitutional symptoms in, 523 
cough in, 523 
definition, 521 
diagnosis, 523 
ear-symptoms in, 523 
edema in, 522 
etiology, 521 
exudate in, 522 

formation of membrane in, 522 
headache in, 523 
impairment of hearing in, 523 



Pharyngitis, acute, impairment of taste in, 

523 
involvement of adjacent structures in, 523 

of lingual tonsil in, 523 
mucous membrane in, 521 

color, 522 
non-infectious, membranous inflamma- 
tion in, 522 
pain in, 523 
pathology, 521 
prognosis, 523 
secretion in, 522 
symptoms, 522 
synonym, 521 
treatment, 524 
urine in, 523; 
voice in, 523 
atrophic, 573 

after chronic inflammatory process, 573 

atrophic rhinitis as cause, 574 

bacteria in, 575 

bacteriological examination, 575 

cough in, 575 

diagnosis, 576 

etiology, 573 

involvement of Eustachian tube in, 575 

of nasopharynx in, 575 
mucous membrane in, 575, 576 
nasal obstruction as cause, 574 
odor in, 576 
pathology, 576 
prognosis, 576 
secretion in, 574, 575 
symptoms, 575 
synonyms, 573 
throat in, 575 
treatment, 576 
trophic lesions as cause, 573 
venous stasis as cause, 573 
catarrhal, acute, 521 
chronic, 560 

acute pharyngitis as cause, 560 

processes as cause, 560 
alterations in blood-supply as cause, 560 
atmosphere as cause, 561 
constitutional diseases as cause, 561 
cough in, 564 

cyanotic congestion as cause, 560 
definition, 560 
diagnosis, 565 

digestive disturbances in, 560, 564 
dust as cause, 565 
etiology, 564 

globus hystericus resembling, 564 
hyperplasia in, 563 
impairment of smell in, 564 

of taste in, 564 
improper use of muscles as cause, 561 
irregularities in formation of pharynx as 

cause, 561 
laryngitis in, 565 
mucous membrane in, 562, 563 
narcotics as cause, 560 
nasal obstruction in, 562, 564 
nervous phenomena as cause, 560 
pain in, 564 
pathology, 562, 568 
pneumonokoniosis as cause, 560, 561 
prognosis, 565 
rhinitis as cause, 561 
secretions in, 563 
sexual excesses as cause, 560 
slanting pharynx as cause, 561 
smoking as cause, 560 
stimulants as cause, 560 
symptoms, 563 
synonyms, 560 
throat-tire in, 564 
treatment, 565 

varicose condition of vessels in, 563 
voice in, 561, 563, 564, 566, 567, 569 
croupous, 529 



838 



INDEX. 



Pharyngitis, croupous, diagnosis, 529 

false membrane in, 529 

infection and contagion in, 529 

streptococcal infection in, 529 

streptococcus pyogenes in, 529 

treatment, 529 
cyanotic, 579 

cough in, 579 

etiology, 579 

high altitude as cause, 579 

pathology, 579 

snow-water as cause, 579 

voice in, 579 
dry, 573. See also Pharyngitis, atrophic. 
exudative, 560 
follicular, 566 

acute pharyngitis as cause, 56/ 

age in, 566 

asthma in, 570 

climate as cause, 567 

constitutional symptoms, 570 

cough in, 566, 570 

definition, 566 

diagnosis, 571 

etiology, 566 
exciting, 567 
predisposing, 566 

exudative form, 569 

follicular laryngitis associated with, 684 

gastric derangements in, 570 

glandular involvement in, 568, 569 

hypertrophy in, 568 

impairment of hearing in, 570 
of smell in, 570 
of taste in, 570 

intestinal derangements in, 570 

irritation in nasopharynx as cause, 567 

mental dulness in, 570 

mucous membrane in, 566, 568, 570 

nervous phenomena as cause, 567 

occupation as cause, 567 

pain in, 570 

prognosis, 571 

secretion in, 569, 570 

sex in, 566 

skin-eruptions in, 570 

spread of inflammatory process, 570 

straining of voice as cause, 567 

symptoms, 569 

synonyms, 566 

throat uneasiness in, 569 

tobacco as cause, 567 

treatment, 571 
folliculous, 566 
gangrenous, 548 

etiology, 548 

glandular involvement in, 549 

odor in, 549 

pain in, 549 

prognosis, 549 

synonym, 548 

temperature in, 549 

treatment, 549 
granular, 566 
hemorrhagic, 551 

definition, 551 

pain in, 551 

symptoms, 551 

treatment, 551 
herpetica, 605 
hypertrophic a lateralis, 570 
in chronic hyperplastic ethmoiditis, 386 
infective, 526 

bacteria in, 527 

definition, 526 

diagnosis, 528 

etiology, 526 

headache in, 527 

hyperplastic rhinitis in, 121 

Uquef action-necrosis in, 527 

mucous membrane in, 527 

pain in, 527 



Pharyngitis, infective, pathology, 527 
prognosis, 527 

pseudobacillus of diphtheria in, 527 
sensitiveness of throat in, 527 
staphylococcus in, 527 
streptococcus as cause, 527 
symptoms, 527 
synonyms, 526 
treatment, 528 
ulceration in, 527 
lateralis, glandular, 552 
cough in, 552 
ear-symptoms in, 552 
etiology, 552 
pain in, 552 
pathology, 552 
symptoms, 552 
treatment, 553 
lithemic, 580 
membranous, 529 
simple, 529 
varieties, 529 
occupation-, 549 
definition, 549 
edema of glottis in, 550 
etiology, 549 

foreign bodies as cause, 549 
synonym, 549 
treatment, 550 
phlegmonous, 526 
preceding lupus of pharynx, 590 
rheumatic, acute, 580 

constant desire to swallow in, 582 

definition, 580 

diagnosis, 582 

etiology, 580 

exposure to cold and dampness as cause, 

581 
involvement of mucous membrane in, 

582 _ 
lithemia in, 581 
mucous membrane in, 581 
pain in, 581, 582 
pathology, 581 
previous attacks, 582 
prognosis, 582 
symptoms, 581 ■ 
synonyms, 580 
throat in, 582 
treatment, 582 
uric-acid diathesis in, 580 
chronic, 584 
definition, 584 
diagnosis, 584 
etiology, 584 

involvement of larynx in, 584 
pathology, 584 
prognosis, 584 
symptoms, 584 
synonym, 584 
throat in, 584 
treatment, 585 
voice in, 584 
sicca, 573 
streptococci, 526 
subacute, 566 
pathology, 566 
symptoms, 566 
treatment, 566 
suppurative, 526, 527 
traumatic, 549 
Pharyngocele, 520 
Pharyngomycosis, 606 

and keratosis of pharynx, differentiation, 613 

bacteria in, 607 

cough in, 607 

diagnosis, 607 

etiology, 606 

leptothrix as cause, 606 

pathology, 607 

prognosis, 608 

symptoms, 607 



INDEX. 



839 



Pharyngomycosis, treatment, 608 
Pharyngoscope, Hays', -42 
Pharyngotyphoid, 557 
Pharynx, actinomycosis of, 600 
death from, 602 
diagnosis, 602 
discharge in, 601 
etiology, 600 

gastric disturbances in, 601 
granulation-tumor in, 600 
metastasis in, 601 
odor in, 601 
pain in, 601 
pathology, 600 
prognosis, 602 
ray-fungus as cause, 600 
swelling in, 601 
symptoms, 601 
systemic symptoms, 601 
treatment, 602 
adhesion of soft palate to, closure of naso- 
pharynx by, 450 
alterations in, in tertiary syphilis of phar- 
ynx, 596 
anemia of, 614 
age in, 615 

constant desire to swallow in, 615 
elongation of uvula in, 615 
mucous membrane in, 615 
secretion in, 615 
sex in, 615 
symptoms, 615 
treatment, 615 
ulcer in, 614 
treatment, 614 
anesthesia of, 615 
etiology, 615 
prognosis, 616 
treatment, 616 
aneurysm of, 614 
angioma of, 242 
angioneurotic edema of, 584 

treatment, 586 
atresia of, congenital, 519 
black tongue involving, 555 
carcinoma of, 271. See also Carcinoma of 

pharynx. 
consumption of, 586 
deformities of, 519 
dilatation of, 520 
diphtheritic paralysis of, 618 
diseases of, 518 

lactic bacteriotherapy in, 528 
diverticulum of, 520 

difficult swallowing in, 520 
etiology, 520 
symptoms, 520 
treatment, 520 
dome of, 26 
ecthyma of, 604 
equinia of, 597 
erythema exudativum of, 604 

multiforme of, 604 
foreign bodies in, 619 
symptoms, 619 
treatment, 620 
glanders of, 597 

acute, abscess in, 598 
bacteria in, 598 

constitutional symptoms in, 598 
fever in, 598 

glandular involvement in, 598 
headache in, 598 
impairment of deglutition and phona- 

tion in, 598 
joints in, 598 
nodules in, 598 
pain in, 598 
secretion in, 598 
sweats in, 598, 599 
swelling in, 598 
symptoms, 598 



Pharynx, glanders of, acute, ulceration in, 598 

and variola, differentiation, 599 

animals as cause, 597 

Bacillus mallei as cause, 597 

chronic, constitutional symptoms, 599 
death in, 599 
discharge in, 599 
glandular involvement in, 599 
impairment of swallowing and speak- 
ing in, 599 
pain in, 599 
swelling in, 599 
symptoms, 599 

diagnosis, 599 

etiology, 597 

farcy buds in, 598 

mallein in, 600 

mucous membrane in, 597 

pathology, 597 

prognosis, 600 

symptoms, 598 

synonyms, 597 

treatment, 600 
hemorrhagic ulceration of, 551 
herpes of, 605 

definition, 605 

diagnosis, 606 

etiology, 605 

mucous membrane in, 605 

pain in, 605 

patches in, 605 

prognosis, 606 

symptoms, 605 

synonyms, 605 

throat in, 605 

treatment, 606 
hyperesthesia of, 616 

treatment, 616 
hyperkeratosis of, 608 
hyperplastic change in, 572 
in chicken-pox, 558 

treatment, 558 
in erysipelas, 555 

prognosis, 556 

symptoms, 556 

treatment, 556 
in exanthemata, 553 
in febrile diseases, 553 
in gout, 556 
in influenza, 557 
in intermittent fever, 556 

treatment, 556 
in la grippe, 557 
in measles, 555 

treatment, 555 
in scarlet fever, 553 
treatment, 554 
in small-pox, 554 

treatment, 555 
in typhoid fever, 557 
in typhus fever, 557 
treatment, 557 
in varioloid, 558 
infectious granuloma of, 586 
irregularities in formation of, as cause of 

chronic pharyngitis, 561 
irritation of, in nasal polypus, 259 
keratosis of, 608 

age in, 6C8 

amvloid degeneration of mucous glands 
in, 610 

and Paget's disease of nipple, micro- 
scopic resemblance, 611 

and pharyngomyeosis, differentiation, 613 

bacteria in, 612 

cells in, 610 

connective-tissue papillae in, 609 

cough in, 612 

definition, 608 

diagnosis, 613 

etiology, 608 

fibrous bands in, 610 



840 



INDEX. 



Pharynx, keratosis of, forms of, 612 

hyaline change in, 611 

keratohyaline, 610 

not dependent on leptothrix, 609 

papillary budding in, 610 

pathology, 609 

quills in, 612, 613 

sex in, 608 

stiffness in throat in, 609, 612 

subepithelial buds in, 609 

symptoms, 612 

synonym, 608 

systemic condition in, 608 

treatment, 613 

tufts in, 612, 613 
lipoma of, 253 
lupus of, 590 

cicatrization in, 591 

course, 591 

diagnosis, 591 

ear-symptoms in, 591 

epiglottis in, 591 

etiology, 590 

involvement of Eustachian tube in, 590 

mucous membrane in, 590, 591 

nodules in, 590, 591 

pathology, 590 

preceded by pharyngitis, 590 

prognosis, 592 

shrinking of uvula in, 591 

symptoms, 590 

tonsil in, 591 

treatment, 592 

tubercular manifestation, 590 

ulceration in, 591 

voice in, 591 
lymphosarcoma of, 282 
malformations of, 519 
malleus humidus of, 597 
mucous membrane of, effect of climate on, 

580 
neuralgia of, 617 

treatment, 617 
neuroses of, 615 

of motion, 617 
nystagmus of, 617 
papilloma of, 235 

symptoms, 235 

treatment, 235 
paralysis of, 617 

and spasm of pharynx, differentiation, 617 

diagnosis, 618 

difficulty in swallowing in, 618 

diphtheritic, 618 

etiology, 617 

facial expression in, 618 

prognosis, 618 

symptoms, 618 

treatment, 619 
paresthesia of, 616 

etiology, 616 

prognosis, 616 

treatment, 617 
pemphigus of, 604, 605 
pneumococcic infection, 548 
diagnosis, 548 
symptoms, 548 
tuberculosis after, 548 
ulceration in, 548 
pulsating arteries of, 613 
reflex nasal neuroses of, 208 
sarcoma of, 281. See also Sarcoma of phar- 
ynx. 
slanting, as cause of chronic pharyngitis, 561 
spasm of, 617 

and paralysis of esophagus, differentia- 
tion, 617 
of pharynx, differentiation, 617 

and stricture of esophagus, differentia- 
tion, 617 

diagnosis, differential, 617 

treatment, 617 



Pharynx, stenosis of, 519 

disease of vertebral column as cause, 520 
enlargement of thyroid gland as cause, 520 
extrinsic, 520 

Hodgkin's disease as cause, 520 
retropharyngeal abscess as cause, 520 
spasmodic, 520 
symptoms, 519 
traumatic, 519 
treatment, 519 
tubercular, 519 
streptococcic infection of, 547 
symptoms, 547 
treatment, 548 
syphilis of, 592 
acquired, 592 
congenital, 592 
diagnosis, 596 
ear-symptoms, 594 
primary, 593 

glandular involvement in, 594 
pain in, 594 
symptoms, 593 
prognosis, 596 
secondary, 594 
cough in, 594 
erythema in, 594 
mucous patches in, 595 
symptoms, 594 
tertiary, 595 

adhesions in, 596 
alterations in pharynx in, 596 
discharge of necrotic tissue in, 596 
gumma-formation, 595 
involvement of brain in, 596 

of vertebrae in, 596 
mucous membrane in, 595 
odor in, 596 
pain in, 596 
ulceration in, 595 
treatment, 597 
syphilitic hyperplasia of, congenital, 592, 593 

treatment, 593 
traumatic stenosis of, 519 
tubercular stenosis of, 519 
tuberculosis of, 586 
cicatrization in, 587 
cough in, 587, 588 
curetment in, 589 
diagnosis, 588 

moth-eaten appearance of mucous mem- 
brane in, 587 
odor in, 588 
otalgia in, 587 
pain in, 587 

painful deglutition in, 587 
prognosis, 588 
pulmonary symptoms, 588 
secretion in, 587 
symptoms, 586 
synonyms, 586 
treatment, 588 
tubercles in, 587 
ulcers in, 587 
voice in, 587 
ulceration of, from rheumatism, 581 
urticaria of, 604, 605 

edema of glottis from, 605 
vault of, 26 
Phenol in sphenopalatine ganglia neuralgia, 

357 
Phillip's electric head-lamp, 33 
Phlebectasia laryngea, 688 
Phlegmon, peripharyngeal, 527 

peritonsillar, 482 
Phlegmonous inflammation, acute, of Ungual 
tonsil, 515 
of antrum of Highmore, 384 
laryngitis, 654, 656 
pharyngitis, 526 
rhinitis, 105, 183 
diagnosis, 105 



INDEX. 



841 



Phlegmonous rhinitis, septic condition from, 
106 
treatment, 106 
tonsillitis, 482 
Phlegm-producing membrane, 22 
Phonation, drawback, 752 

function of nasal cavities, 28 
Photophobia in secondary stage of acquired 

nasal syphilis, 150 
Phthisis, laryngeal, 703 
nasal, 166 
nasalis, 166 
Physiologic alphabet, Makuen's, 757 
Phvsiolop;y of accessory nasal cavities, 17, 27, 

29 
Pierce's divulsor, 485 
tonsil-clamp, 499 
tonsil-punch, 497 
Pillars, sarcoma of, 281 
Pincet, Brun's epiglottis, 653 
Pitch of voice, 734 

modification, 733 
Pituitary membrane, 22 

Plethora, color of mucous membrane of ac- 
cessory cavities in, 23 
Plethoric rhinitis, 138 
Pleuritic cough, 634 
Plexus, Cruveilhier's, 242 

venous, 24 
Pneumobacillus of Friedlander, 71 
Pneumococcic infection of pharynx, 548 
diagnosis, 548 
symptoms, 548 
tuberculosis after, 548 
ulceration in, 548 
Pneumococcus, Friedlander's, 70 

of Frankel, 71 
Pneumonia, catarrhal, after spasmodic laryn- 
gitis, 651 
in nasal glanders, 176 
Pneumonokoniosis as cause of chronic phar- 
yngitis, 560, 561 
Pocket set, illuminating, 31 
Poisonous saliva, 57 

Pollen as cause of hyperesthetic rhinitis, 200 
catarrh, 194 

effect of, in hyperesthetic rhinitis, 196, 197 
Polypoid hypertrophy and nasal polypus, 

differentiation, 259 
Polyp-scissors, 261 
Polypus, bleeding, of septum, 347 
in nasal hydrorrhea, 143 
nasal, 256 

and lupus, differentiation, 173 

and mucoid degeneration, differentiation, 

260 
and polvpoid hypertrophy, differentia- 
tion, 259 
associated with hyperplastic rhinitis, 119 
asthma from, 259 
bleeding, 248 
blood-supply in, 259 
color, 257 
diagnosis, 259 
discharge in, 259 
effect of weather on, 257 
etiology, 256 
eye-symptoms in, 259 
facial deformity from, 259 
fibrous, 261. See also Myxofibroma, nasal. 
gelatinous, 265 
impairment of smell in, 259 
irritation of pharynx and larynx in, 259 
mucous, 265 

nasal obstruction in, 259 
nerve-filaments in, 259 
papillary edematous, 257 
pathology, 258 
pedunculated variety, 257 
prognosis, 260 
reflex neuroses in, 259 
sessile variety, 257 



Polypus, nasal, size and shape, 257 
symptoms, 259 
systemic derangement in, 257 
treatment, 260 
voice in, 259 
Postnasal catarrh, acute, 421 
chronic, 425 

from ulceration of uvula, 448 
cavity, anatomy of, 25 

sensation of accumulated material in, in 
atrophic rhinitis due to pre-existing 
lesion, 132 
lamp, Kyle's, 41 
space, 18 

in chronic nasopharyngitis, 430 
syringe, 47 
Posture in tonsillectomy, 495 
Potassium iodid and salvarsan in tertiary 

syphilis, 157 
Potter's serrated scissors, 249 
Pouches of larynx, dilatation, 629 
Preglottic tonsillitis, 514. See also Tonsillitis, 

preglottic. 
Pregnancy, varices of lingual tonsil in, 517 
Probe, nasal, 47 
Prof eta's law of immunity in nasal syphilis, 

146 
Progressive bulbar paralysis of pharynx, 618 

symptoms, 618 
Prolapse of laryngeal ventricles, 750 
Pruritic rhinitis, 194 
Psellism, 749 

Pseudobacillus of diphtheria in infective phar- 
yngitis, 527 
Pseudocroup, 649 
Pseudodiphtheria, bacillus of, 70 
Pseudokousma, 749 
Pseudomembrane in hay fever, 203 
Pseudomembranous croup, 661 

and spasmodic laryngitis, differentiation, 
651 
inflammation of mucous membrane, 64 
laryngitis, 661 
rhinitis, 97 
primary, 97 
Puberty, change of voice at, improper, 752 
larynx in, 752 
treatment, 752 
cough of, 633 
Pulmonary diseases from foreign bodies, 716 
hemorrhage and laryngeal hemorrhage, dif- 
ferentiation, 714 
symptoms of membranous laryngitis, 664 

of tuberculosis of pharynx, 588 
tuberculosis and foreign body in larynx, 
differentiation, 729 
Pulsating arteries of pharynx, 613 
Pulse in diphtheria, 534 

in spasmodic laryngitis, 650 
Punch, Farlow's tonsil, 497, 498 

Pierce's, 497 
Purpura hemorrhagica of larynx, 642 
Purulent ethmoiditis, 387. See also Ethmoid- 
itis, suppurating. 
inflammation, acute, of antrum of High- 
more, 364. See also Empyema of 
antrum of Highmore. 
of frontal sinus, 402. See also Empy- 
ema of frontal sinus. 
chronic, of antrum of Highmore, 366. 
See also Empyema of antrum of 
Highmore. 
of frontal sinus, 404. See also Empyema 
of frontal sinus. 
laryngitis, 654, 656 
nasal catarrh, 140 

rhinitis, 139. See also Rhinitis, purulent. 
Pus in acute purulent inflammation of antrum 
of Highmore, 365 
of frontal sinus, 403 
in chronic purulent inflammation of frontal 
sinus, 405 



842 



INDEX. 



Pus in confined suppuration of antrum of 
Highmore, 369 
treatment, 373 
in secondary stage of acquired nasal syph- 
ilis, 147 
in tonsillar abscess, 483 
pent-up, in antrum of Highmore, 368 
treatment, 373 
in frontal sinus, 405 
Pustular inflammation of mucous membrane, 

66 
Putrid sore throat, 530, 548 
Pyemia and nasal glanders, differentiation, 176 
in confined suppuration of frontal sinus, 409 
Pyogenic cocci, 71 



Quincke's disease, 585 

Quinlan's syringe for injection of paraffin, li 

Quinsy, 482 



Race predisposing to hyperesthetic rhinitis, 

198 
Rag-weed fever, 194 
Rales, absence of, in varices of lingual tonsil, 

517 
Raspberry form of hyperplastic rhinitis, 119 
Rattling cough, loose, 633 
Ray-fungus, 67 

as cause of actinomycosis of pharynx, 600 
Receptacle for waste cotton, 38 
Recessus pharyngeus, 26 
Rectal method of ether anesthesia, 468 
Recurrent laryngeal nerve, 771 

paralysis, 769. See also Laryngeal paral- 
ysis, recurrent. 
ulcerative laryngitis, 696 
Red nose, 215 

Reflecting mirrors for illumination, 31 
Reflex nasal neuroses, 193. See also Neuroses, 

reflex nasal. 
Regurgitation in hypertrophic tonsillitis, 489 
Reminders in tertiary period of acquired nasal 

syphilis, 151 
Renal cough, 634 

Resonance tube in production of voice, 737 
size of, controlling volume, tone, and 
timbre of voice, 737 
Resonant cough, deep, 633 
Respiration, difficult, in anesthesia, 467 

in secondary stage of acquired nasal 
syphilis, 150 
in cryptic tonsillitis, 475 
in edematous laryngitis, 658 
in laryngeal hemorrhage, 713 
in membranous laryngitis, 663 
in spasm of larynx in children, 647 
in suppurative laryngitis, 655 
interference with, in sarcoma of larynx, 285 
Respiratory function of nasal cavities, 27 
neuroses, 193 
tract, adenocarcinoma of, 286 

adenoma of, 238. See also Adenoma of 

respiratory tract. 
angioma of, 240 
carcinoma of, 267 
chondroma of, 243 
cysts of, 287 

embrvonic connective-tissue tumors of, 
278 
epithelial tumors of, 267 
exostosis of, 245 
treatment, 246 
fibroma of, 247 

and adenoma, differentiation, 240 
lesions of, as cause of congestion of mu- 
cous membrane, 114 
lipoma of, 253 
mixed tumors of, 286 

mucocele of, 265. See also Mucocele of 
respiratory tract. 



Respiratory tract, myxocarcinoma of, 286 

myxoma of, 256. See also Polypus, 

nasal. 
osteoma of, 254 
papilloma of, 234 
sarcoma of, 278 
subdivisions of, 17 
telangiectoma of, 286 

epistaxis in, 286 
teratoma of, 286 
tumors of, 232 
classification, 232 
malignant, 232 
non-malignant, 232 
Retention-cysts, 287 

of antrum of Highmore, 384 
treatment, 287 
Retronasal catarrh, acute, 421 

chronic, 425 
Retropharyngeal abscess, 602 

and membranous laryngitis, differen- 
tiation, 664 
as cause of stenosis of pharynx, 520 
associated with caries of cervical verte- 
brae, 603 
cough in, 603 
cri de canard in, 56 
diagnosis, 603 

differential, 603 
fever in, 603 
in adults, 603 
in children, 602 
pain in, 603 
prognosis, 603 
treatment, 604 
Rheumatic angina, 580 

diathesis predisposing to hay fever, 199 
laryngitis, 655. See also Laryngitis, rheu- 
matic. 
pharyngitis, acute, 580. See also Phar- 
yngitis, rheumatic, acute. 
chronic, 584. See also Pharyngitis, 
rheumatic, chronic. 
sore throat, 580 

tonsillitis, 478. See also Tonsillitis, rheu- 
matic. 
Rheumatism, acute articular, acute simple 
rhinitis in, 83 
laryngitis in, 642 
as cause of chondritis of larynx, 669 
diagnosis of chondritis of larynx due to, 675 
excessive alkalinity of secretion as cause, 58 
laryngeal, 655 
nasal ulcers in, 190 

pathology of chondritis of larynx due to, 671 
predisposing to acute simple rhinitis, 75 
prognosis of chondritis of larynx due to, 676 
symptoms of chondritis of larynx due to, 674 
tonsil and, relationship, 492 
treatment of chondritis of larynx due to, 677 
ulceration of pharynx from, 581 
Rhinitis, acute, idiopathic, 74 
simple, 72 

asthma predisposing to, 75 
bacteriology, 75 
causes, _ 74 
exciting, 75 
predisposing, 74 
chilling of body as cause, 75 
climate predisposing to, 75 
clothing predisposing to, 75 
complications, 78 
contagiousness, 75 
definition, 74 
diagnosis, 78 
diplococcus coryzse in, 75 
drainage in, 77 
epidemic, 75 
etiology, 74 

foreign bodies as cause, 76> 
from inflammation of accessory cavi- 
ties, 75 



INDEX. 



843 



Rhinitis, acute, simple, hay fever predispos- 
ing to, 75 
. heredity as cause, 75 
idiopathic, 74 

form, symptoms, 77 
idiosyncrasy to, 75 
in acute articular rheumatism, 83 
in anemia, 84. See also Anemic rhini- 
tis. 
in constitutional diseases, 82 
in diabetes mellitus, 83 
in diphtheria, 83 
in enteric fever, 83 
in erysipelas, 84 
in infectious diseases, 75 
in lithemia, 91 
in measles, 82 
in pertussis, 83 
in scarlet fever, 83 
in scorbutus, 84 
in scrofula, 85 
in small-pox, 83 
in tuberculosis, 85 
in typhoid fever, 83 
in variola, 83 
in whooping-cough, 83 
in young, 91 

and purulent rhinitis, differentiation, 

92 
and specific rhinitis, differentiation, 

91 
complications, 93 
etiology, 91 
prognosis, 92 
symptoms, 91 
treatment, 92 
labial herpes in, 77, 78 
leukocytes in, 76 

lowered bodily resistance as cause, 74 
malformations of nasal passages as 

cause, 75 
nasal discharge in, 77 
occupation, 76 
pathology, 76 
prognosis, 78 
rheumatism predisposing to, 75 

as cause, 76 
serum in, 76 

sexual excesses predisposing to, 75 
sneezing in, 77 
stuffiness in nose in, 77 
symptoms, 76 
synonyms, 74 

syphilis predisposing to, 75 
tendency to, in chronic simple rhinitis, 

109 
traumatic, 76 
treatment, 78 

tuberculosis predisposing to, 75 
voice in, 77 
anemic, 84. See also Anemic rhinitis. 
as cause of chronic pharyngitis, 561 
atrophic, 108, 124 

as cause of atrophic pharyngitis, 574 

as local manifestation of constitutional 

lesion, 137 
atrophy of turbinates in, 128 
bacteria in, 130 
chronic, 125 
classification, 125 

due to pre-existing local lesion, 129 
accessory cavities in, 135 
age occurring, 129 
alteration of voice in, 135 
bleeding from nose in, 132 
complications, 135 
cough in, 133 

crusts or slugs in, 132, 133 
diagnosis, 135 
dyspeptic symptoms, 133 
epistaxis, in 133 
etiology, 129 



Rhinitis, atrophic, due to pre-existing local 
lesion, Eustachian tubes in, 135 
eyes in, 135 
facies in, 134 
general condition in, 133 
impairment of hearing in, 134, 135 
of smell in, 134 
of taste in, 134 
lactic-acid bacteria in treatment of, 

136 
mucous membrane in, 132, 134 
nasopharynx in, 135 
nervous complications in, 135 
odor in, 132, 133 
pain in, 133 
pathology, 130 
prognosis, 135 
secretion in, 133 
sensation of accumulated material 

in postnasal cavity in, 132 
snub-nose in, 134 
symptoms, 132 
treatment 135 
turbinates in, 132 
ulceration of septum in, 132 
due to trophic lesions, 139 
fetid, 125 

general remarks on, 126 
in aged, 129 
in children, 127 

mucous membrane in, pathological alter- 
ations, 130 
ozena in, 129 
primary, 126 
secondary, 126 

to lesion elsewhere, 137 

accessory sinuses in, 139 
atrophv of mucous membrane in, 

138 
complications, 139 
diagnosis, 138 
etiology, 137 
Eustachian tubes in, 139 
exudation in, 138 
eyes in, 138 
headache in, 138 
lacrimal duct in, 139 
loss of smell in, 138 
mucous membrane in, 137 
nasal obstruction in, 138 
neuralgia of nasal nerve in, 139 
pathology, 137 
prognosis, 138 
secretion in, 138 
symptoms, 138 
treatment, 139 
ulceration in, 139 
voice in, 138 
synonyms, 125 
ulcers in, 127 
atrophica, 125 
simplex, 125 
caseosa, 86 
caseous, 86 
synonyms, 86 
treatment, 87 
catarrhal, 74 
catarrhalis, 74 
cholesteatomatous, 86 
chronic, 107 
atrophic, 125 

edematous, 144. See also Rhinitis, cy- 
anotic. 
fetid, 125 
hypertrophic, 116 
simple, 107 

accessory cavities complicated in, 109 
aural complications, 109 
complications, 109 
constitutional debility in, 108 
definition, 107 
diagnosis, 109 



i 



844 



INDEX. 



Rhinitis, chronic, simple, discharge in, 108 

enlarged turbinates in, 110 
removal, 111 

etiology, 107 

eye complications, 109 

formation of crusts in, 108 

gastric derangement in, 109 

headache in, 108 

impairment of smell in, 108, 109 
of taste in, 109 

leukocytes in, 108 

mucous membrane in, 109 

neuroses in, 108 

pathology, 108 

prognosis, 109 

symptoms, 108 

synonyms, 107 

tendency to acute rhinitis in, 109 

treatment, 109 

constitutional, 112 
local, 113 
cirrhotic, 125 
croupous, 97 

and nasal diphtheria, differentiation, 99 

definition, 97 

diagnosis, 98 

differential diagnosis, 99 

pathology, 97 

prognosis, 99 

symptoms, 98 

synonyms, 97 

treatment, 99 

internal, 100 

local, 99 
cyanotic, 144 

associated with asthma, 144 

cyanotic congestion in tissues remote to 

organ in, 144 
definition, 144 
diagnosis, 144 
etiology, 144 
hepatic involvement, 144 
pathology, 144 
prognosis, 144 
swelling of turbinates, 144 
symptoms, 144 
synonym, 144 
treatment, 144 
ulceration in, 144 
diphtheritic, 102 
chronic form, 102 
synonym, 102 
edematous, acute, 105 

etiology, 105 

treatment, 105 
chronic, 144. See also Rhinitis, cyanotic. 
fetid, 125 

atrophic, 125 
chronic, 125 
fibrinoplastic, 100 
chronic form, 101 
etiology, 100 

false membrane in, 100, 101 
general remarks on, 101 
treatment, 101 
fcetida atrophica, 125 
hyperesthetic, 104, 125 

actinic rays, condition simulating due to, 

199 
altered chemistry of secretion as cause, 

195 
areas of hyperesthesia in nasal mem- 
brane in, 202 

of increased intranasal irritation in, 201 
associated with reflex nasal asthma, 210 
asthmatic symptoms in, 204, 205 
catarrhal conditions predisposing to, 199 
chemistry of saliva in, 195 
definition, 194 
diagnosis, 205 
diseases of nasal structures predisposing 

to, 199 



Rhinitis, hyperesthetic, effect of pollen in, 

196, 197 
etiology 194 

exciting, 199 

predisposing, 194 
geographic distribution, 198 
gouty diathesis predisposing to, 199 
headache in, 203 
high altitude in, 198 
inherited tendency to, 195 
malformations of nasal structures pre- 
disposing to, 199 
mucous membrane in, 195, 196, 203 
nervous habit predisposing to, 194, 195, 

198 
pain in, 203 

pallor of mucous membrane in, 201 
pathology, 201 
periodical, 194 
pollen as cause of, 200 
prognosis, 205 
pseudomembrane in, 203 
race predisposing to, 198 
rheumatic diathesis predisposing to, 199 
season predisposing to, 199 
sun's rays, condition simulating due to, 

199 
symptoms, 203 

of attacks, 203 
synonyms, 194 
treatment, 205 

constitutional, 206 

of irregularities of nasal cavities and 
hypersensitiveness, 207 

of neurotic temperament, 207 
hyperesthetica, 194 
hyperplastic, 116 

altered timbre of voice in, 119 
appearance of hyperplastic tissue in, 119 
associated with deflection, exostosis, or 

enchondrosis of septum, 118 
asthma in, 121 
bronchitis in, 121 
chorea in, 121 
climate as cause, 117 
color of mucous membrane in, 118 
complications, 121 
condition of inferior turbinate in, 118, 119 

of middle turbinate in, 118, 119 
cough in, 119 
deafness in, 121 
definition, 116 
diagnosis, 119 

digestive disturbances in, 121 
discharge in, 118 
electrolysis in, 122 

engorgement of mucous membrane in, 118 
epilepsy in, 121 
etiology, 116 
eye-complications in, 121 
eye-lesions in, 119 
face-ache in, 119 
headache in, 119, 121 
hyperplastic tissue in, 118 
hypersecretion in, 119 
impairment of hearing in, 119 

of sensibility of mucous membrane in, 
118 

of smell in, 118, 121 
increase in turbinated bone in, 118 

of connective-tissue elements of sub- 
mucosa in, 116 
inflammatory processes in, 118 
involvement of nasal fossae in, 119 
mouth-breathing in, 118 
mucous membrane in, 117 
mulberry form, 119 
nasal breathing in, 118 

obstruction in, 118 

polyps associated with, 119 
nasopharyngitis in, 121 
obstruction of nasal duct in, 121 



INDEX. 



845 



Rhinitis, hyperplastic, obstruction of sinus 
optics in, 121 

occlusion of lacrimal canal in, 119 

pathology, 117 

pharyngitis in, 121 

predisposing to acute simple rhinitis, 75 

prognosis, 120 

raspberry form, 119 

roofs of fossae in, 119 

secretion in, 118 
nasal cavity in, 119 

septum in, 119 

spasms of glottis in, 121 

swollen mucous membrane in, 118 

symptoms, 117 

synonyms, 116 

thickened mucous membrane in, 118 

tracheitis in, 121 

treatment, 121 

tumors in, 121 
hypertrophic, 108, 116 

chronic, 116 
in chronic epipharyngeal periadenitis, 434 
in hereditary nasal syphilis, 163 
intumescent, 115 

condition of voice in, 115 

definition, 115 

dryness and tickling of throat in, 115 

excess of mucus in, 115 

skin of nose in, 115 

swelling of mucous membrane in, 115 

symptoms, 115 

taking cold in, 115 

treatment, 115 
lithemic, 90, 194 

treatment, 90 

chemical analysis of secretions in, 90 
constitutional, 90 
local, 90 
membranous, 97 

etiology, 97 
obstructive, 116 
occupation-, 102 

definition, 102 

degeneration in, 103 

etiology, 102 

pathology, 103 

prognosis, 103 

symptoms, 103 

synonym, 102 

treatment, 103 

ulceration in, 103 
cedematosa chronica, 144 
pharyngeal tonsil in, 459 
phlegmonous, 105, 183 

diagnosis, 105 

septic condition from, 106 

treatment, 106 
plethoric, 138 
pruritic, 194 
pseudomembranous, 97 

primary, 97 
purulent, 139 

and acute simple rhinitis in young, dif- 
ferentiation, 91 

bacteria in, 140 

definition, 139 

discharge in, 140 

embryonic cells in, 140 

etiology, 140 

in children, treatment, 141 

in newborn, etiology, 140 

mucous membrane in, 140 

odor in, 140 

pathology, 140 

prognosis, 141 

symptoms, 140 

synonym, 140 

treatment, 141 
sclerotic, 125 
scorbutic, 84 
scrofulous, 85 



Rhinitis, scrofulous, synonyms, 85 
treatment, 86 
sicca, 125 
simplex, 107 
specific, 145 

and acute simple rhinitis in young, dif- 
ferentiation, 91 
strumous, 85 
syphilitic, 145 
traumatic, 102 
tuberculous, 85 
ulcerative, 104 
Rhinolalia aperta, 449 
Rhinoliths, 224 

characteristics, 224 
chemistry, 225 
definition, 224 
diagnosis, 225 
etiology, 224 
pathology, 224 
prognosis, 225 
site, 224 
symptoms, 225 
synonyms, 224 
treatment, 225 
Rhinopharyngitis, 441 
acute, 421 
chronic, 425 

mutilans, definition, 441 
diagnosis, 442 
etiology, 441 
pathology, 441 
prognosis, 442 
sore throat in, 441 
symptoms, 441 
treatment, 442 
ulcer in, 441 
Rhinorrhagia, 217. See also Epistaxis. 
Rhinorrhea, 141. See also Hydrorrhea, nasal. 
Rhinoscleroma, 68, 180 

affecting adjacent structures, 181 
and epithelioma, differentiation, 181 
and keloid, differentiation, 181 
and scleroma of larynx, 689 
and syphilis, differentiation, 181 
bacillus of, 180 _ 
cartilage-formation in, 181 
cells in, 180 
complications, 182 
definition, 180 
diagnosis, 181 
etiology, 180 
nodules in, 181 
pathology, 180 
prognosis, 181 
swelling in, 181 
symptoms, 181 
treatment, 182 
Rhinoscope, 98 
Rhinoscopy, 35 
anterior, 35 
posterior, 36 

method of holding mirror in, 38 
Richard's modification of Schultz's adenotome, 
469 
tracheotomy tube, 787 
Richardson's method of finger enucleation of 

tonsil, 504 
Roe's operation for deformity from abscess of 
septum, 341 
for septal deviation, 323 
septum forceps, 300 
Rontgen rays in cancer of larynx, 278 
in detecting foreign bodies, 716 
in laryngology and rhinology, 42 
Rose acne, 214 
catarrh, 194 
cold, 194 
fever, 194 
Rosenmuller, fossa of, 26, 44 
Roux's antitoxin syringe, 542 
Rudimentary malformations of uvula, 443 



846 



INDEX. 



Rum cough, 560 

Rupture in confined suppuration of frontal 
sinus, 406, 407 

in suppurating ethmoiditis, 390 

of hematoma, epistaxis after, 218 

in tonsillar abscess, 483 

of varices of lingual tonsil, 517 
Rye fever, 194 



Saddle-back nose, White's operation for, 339 
Sajous' laryngeal forceps, 719 

snare, 260 
Saliva, ammoniacal salts in, 57 
biliary material in, 56 
chemistry of, altered, 53 

in hyperesthetic rhinitis, 195 
etiologio influence, 57 
hyperacid, 56 
hypo-acid, 56 
in diagnosis, 55 
in hemorrhagic laryngitis, 667 
odor of, 56 
poisonous, 57 
study of, 56 
sulphocyanid in, 57 
Salvarsan and iodid of potassium in tertiary 

syphilis, 157 
in syphilis, 156 

after positive Wassermann reaction, 157 

contra-indieations, 158 

intravenous injection, 158 
apparatus for, 159 
Herxheimer's reaction after, 160 
temperature after, 160 

mercury after, 157 

neuro-recurrences after, 161 

of larynx, 703 

provocative injection, 161 

recurrences after, 1-61 
in syphilitic diseases of eye, 158 

ulceration, 158 
influence of, on Wassermann reaction, 161 
Sarcoma of antrum of Highmore, 383 
of ethmoidal sinuses, 393 
of fauces, 281 
of larynx, 284 

age occurring, 284 

cachexia in, 285 

diagnosis, 285 

hemorrhage in, 285 

interference with respiration in, 285 

pain in, 285 

prognosis, 285 

secretion in, 285 

symptoms, 285 

treatment, 285 

ulceration in, 285 

voice in, 285 
of nasopharynx, 280 

course, 280 

diagnosis, 280 

discharge in, 280 

etiology, 280 

general health in, 280 

hemorrhage in, 280 

impairment of hearing in, 280 

nasal obstruction in, 280 

pain in, 280 

prognosis, 280 

symptoms, 280 

treatment, 281 

ulceration in, 280 
of nose, 278 

deformity in, 279 

diagnosis, 279 

discharge in, 279 

hemorrhage in. 279 

mucous membrane in, 279 

myxofibroma as nidus for development of, 
262 

nasal obstruction in, 279 



Sarcoma of nose, pain in, 279 
pathology, 278 
prognosis, 280 
symptoms, 279 
treatment, 280 
ulceration in, 279 
of pharynx, 281 
cachexia in, 282 
diagnosis, 282 
dyspnea in, 282 
edema in, 282 
hemorrhage in, 282 
obstruction in, 282 
pathology, 282 
prognosis, 282 
secretion in, 282 
symptoms, 282 
treatment, 282 
ulceration in, 282 
voice in, 282 
of pillars, 281 
of respiratory tract, 278 
of soft palate, 281 
of sphenoidal sinuses, 398 
of tonsil, 283 

and carcinoma, differentiation, 284 
contents of, 283 
Czerny's operation for, 284 
diagnosis, 284 

differential, 284 
involvement of glands of neck after, 

281 
odor in, 283 
pain in, 283 
prognosis, 284 
removal by incision through neck, 284 

through mouth, 284 
secretion in, 283 
symptoms, 283 
treatment, 284 
ulceration in, 283 
voice in, 283 
Sass's tubes, 46 
Saw, Kyle's nasal, 121 
Saw-file, Fetterolf's, 244 
Scar-formation after nasal lupus, 172 
Scarlet fever, acute laryngitis in, 640 
simple rhinitis in, 83 
nasal ulcers in, 190 
pharynx in, 553 
treatment, 554 
Scheppegrell's laryngeal electrode, 711 

snare, 237 
Schneiderian membrane, 22 
Schroetter's forceps, 252 

method of incising stenotic tissue in larynx, 
630 
Schultze, olfactorial cells of, 24 
Schultz's adenotome, Richards' modification, 

469 
Schwellenkorper, 24 
Scissors, Grant's, 253 
polyp-, 261 
Potter's, 249 
Scleroma of larynx, 689. See also Larynx, 

scleroma of. 
Sclerosis of middle ear in chronic epipharyn- 
geal periadenitis, 433 
Sclerotic rhinitis, 125 
Scorbutic rhinitis, 84 
ulcers, nasal, 186 
treatment, 186 
Scrofulous ozena, 85 
rhinitis, 85 
synonyms, 85 
treatment, 86 
Season predisposing to hvperesthetic rhinitis, 
199 
to reflex nasal asthma, 210 
to taking cold, 73 
Secretion, excess of ammonia in, effect of, on 
mucous membrane, 58 



INDEX. 



847 



Secretion, excessive alkalinity, as cause of rheu- 
matism, 58 
effect of, on joints, 58 

on mucous membranes, 58 
Self-consciousness in speaking, 745 
Self-retaining nasal speculum, 308 
Septal bone-forceps, 308 

Septum, abscess of, 335. See also Abscess of 
septum. 
anatomy, 19, 289 
angioma of, 347 
angiomyxoma of, 347 
arteries of, 290 
bleeding polvp of, 347 
blood-cysts of, 28S, 347 

treatment, 347 
caries of, 328 

cartilage and bones of, fig. 3 
cartilages of, 289 
lower lateral, 290 
upper lateral, 289 
cartilaginous framework of, 289 
chisel, 308 

Lewis', 308 
crushing, Kyle's forceps for, 300 
deformities of, 293 
deviation and deflection, 19, 294 
congenital, 296 
from disease, 294 
hvperplastic rhinitis associated with, 

118 
traumatic, 294 
treatment, 297 

age for operating, 327 

alphabetical operations, 299 

Asch's operation as modified bv 

Thorner, 313 
Ballenger's operation, 319 
Brown's operation, 325 
Casselberry's operation, 323 
Chatelier's submucous method, 299 
Douglass' operation, 322 
Freer's operation, 320 
Gleason's operation, 316 
history and list of operations for, 312 
Irjgal's operation, 314 
Killian's operation, 317 
Moure's operation, 323 
operation for deflection due to dis- 
ease of central incisors, 312 
with external deformity, 311 
with internal deformitv, 312 
with redundancy, 304," 306 
for simple curvature, 300 

forceps for crushing, 301 
method of controlling line of 

fracture, 301 
operation for triangle deflec- 
tion, 302 
postoperative treatment, 301 
removal of large turbinates, 
302 
for splitting of two halves, 304 
pressure by tubes, 299 
Roe's operation, 323 
submucous resection, 309 
after-treatment, 311 
Watson's operation, 314 
window resection, 320 
Yankauer's operation, 321 
diseases of, 289 
dislocation of, 296 
edema of, 335 

treatment, 335 
enchondrosis of, hyperplastic rhinitis as- 
sociated with, 118 
exostosis of, hvperplastic rhinitis associated 

with, 118 
formation of, 19 
hematoma of, 347 
treatment, 347 
in hyperplastic rhinitis, 119 



Septum, malformations of, 292 
mucous membrane of, 289 

swollen, in hyperplastic rhinitis, 118 
nerve-supply of, 290 
perforation of, 331 
age in, 333 
etiology, 331 

list of causes, 333 
pathologv, 333 
sex in, 333 
symptoms, 334 
treatment, 334 
perichondrium of, 289 
submucous infiltration of, 335 
synechia of, 325. See also Synechia. 
svphilis of. 346 
thickness of, 19 
tumors of, 347 
ulceration of, 328 
age in, 329 

bacteria influencing, 329 
etiology, 328 
in atrophic rhinitis due to pre-existing 

lesion, 132 
site, 329 
syphilitic, 329 
treatment, 330 
veins of, 290 
Septum-knife, Allen's, 305 

Kyle's, 111 
Serous exudate ir> cryptic tonsillitis, 474 
Serum, antitoxic, in diphtheria, 541 
dose, 543 

early use. 543, 544 
in acute simple rhinitis, 76 
Sesamoid cartilages, 290 
Sex in anemia of pharynx, 615 
in cancer of larynx, 275 
in follicular pharyngitis, 566 
in hypertrophic tonsillitis, 487 
in keratosis of pharynx, 608 
in perforation of septum, 333 
predisposing to epistaxis, 217 
Sexual excesses as cause of chronic phar- 
yngitis, 560 
predisposing to acute simple rhinitis, 75 
excitement as cause of congestion of mucous 

membrane, 115 
organs, affections of, as reflex nasal neurosis, 
215 
Sialosemeiology, 53 
Sinexon's nasal dilator, 302 
Singers' nodules, 266, 691 
definition, 691 
diagnosis, 693 
etiologv, 691 
pathology, 692 
prognosis, 693 
symptoms, 693 
synonvms, 691 
treatment, 693 
voice in, 693 
Singing, definition of, 734 

Sinus, cavernous, thrombosis of, eye signs, 420 
from suppurating ethmoiditis, 390, 391 
Sinuses, accessory, bone-cysts of, 383 - 
diseases of, 348 

amaurosis in, 419, 420 
amblyopia in, 419, 420 
asthenopia in, 420 
blepharospasm in, 419, 420 
blindness from, 351, 419, 420 
edema of eyelids from, 351 
eye-symptoms from, 331, 354, 419 
headache in, 354, 357 
lesions of teeth from, 351 
meningitis after, 352 
negative air-pressure in, 378 
neuralgia in, 354 
neuralgic pains in, 354 
orbital abscess secondary to. 351 
paralysis of eye-muscles from, 351 



848 



INDEX. 



Sinuses, accessory, diseases of, reflex symp- 
toms, 420 
relation of, to eye, 416, 419 
vaccine therapy in, 93, 94 
dosage, 96 
indications, 94 
ethmoidal, actinomycosis of, 393 
anatomy, 21 
carcinoma of, 393 
catarrhal inflammation, 385 
diagnosis, 385 
symptoms, 385 
treatment, 386 
diseases of, 384 
fibroma of, 393 
glanders of, 393 
mucocele of, 392 
diagnosis, 392 
symptoms, 392 
treatment, 393 
myxoma of, 393 

non-infected fluid-retention in, 392 
osteoma of, 393 
sarcoma of, 393 
specific inflammations, 393 
suppuration of, 387. See also Ethmoid- 
itis, suppurating . 
syphilis of, 393 
tuberculosis of, 393 
tumors of, 393 
treatment, 393 
frontal, diseases of, 399. See also Fron- 
tal sinus. 
infection of, 350 

inflammatory processes involving, 349 
irregularities in formation of, 350 
dental lesions from, 351 
nasal lesions from, 351 \ 

layers of, 23 

lesions of, nasal lesions from, 51 
maxillary, anatomy, 22 
mucous membrane of, 22, 349 
color, 23 

in anemia, 23 
in plethora, 23 
destruction, 349 
structure, 23 
orbital cellulitis from, 351 
pathologic alterations of, 348 
size and shape, 350 
sphenoidal, diseases of, 394. See also 

Sphenoidal sinuses. 
suppuration of, 350 
transillumination of, 372 
variations in thickness of walls, 350 
cavernous, suppuration of, from empyema 

of sphenoidal sinus, 397 
maxillary, 358. See also Antrum of High- 
more. 
outlets, obstruction of, in hyperplastic 
rhinitis, 121 
Sinusitis, chronic, lactic-acid bacteria in treat- 
ment of, 137 
vaccine therapy in, 94 
frontal, chronic, vaccine therapy in, 94 

eye signs, 419 
maxillary, eye signs, 419 
sphenoidal, eye signs, 419 
Skin in membranous laryngitis, 663, 664 
involvement of, in nasal glanders, 175 
of nose in intumescent rhinitis, 115 
sensitive, predisposing to taking cold, 73 
Skin-eruptions in follicular pharyngitis, 570 
Skin-lesions in hereditary nasal syphilis, 

163 
Slanting pharynx as cause of chronic phar- 
yngitis, 561 
Sleep, loss of, in empyema of sphenoidal 

sinus, 396 
Slit-like nostril in catarrhal diathesis, 52 
Sluder's method of tonsillectomy, 502 
Small-pox. See Yariola. 



Smell, impairment of, in atrophic rhinitis due 
to pre-existing lesion, 134 
in chronic hyperplastic ethmoiditis, 386 
pharyngitis, 564 
simple rhinitis, 108, 109 
in confined suppuration of frontal sinus, 

406 
in fibroma of nasal passage, 248 
in follicular pharyngitis, 570 
in hyperplastic rhinitis, 118, 121 
in nasal polypus, 259 
in pharyngeal tonsil, 464 
in secondary stage of acquired nasal syph- 
ilis, 150 
in suppurating ethmoiditis, 389 
loss of, 192 

in acquired tertiary nasal syphilis, 151 
in atrophic rhinitis secondary to lesion 

elsewhere, 138 
in ozena, 124 
perversion of, 191 
Smoke predisposing to taking cold, 74 
Smoking as cause of chronic pharyngitis, 560 
Snare, Gibb's, 243 
Lewis', 502 
Sajous', 260 
Scheppegrell's, 237 
Sneezing, 193 

in acute simple rhinitis, 77 
in nasal hydrorrhea, 142 
in secondary stage of acquired nasal syph- 
ilis, 150 
Snow-water as cause of cvanotic pharyngitis, 

579 
Snub-nose in atrophic rhinitis due to pre- 
existing local lesion, 134 
Snuffles, 74, 162, 163 
Soft palate, diseases of, 443. See also Palate, 

soft, diseases of. 
Soprano voice, 734 
Sore throat, aphthous, 605 

clergyman's, 560, 566, 684 
gouty, 580, 584, 655 
hospital, 526 

in rhinopharyngitis mutilans, 441 
membranous, 605 
putrid, 530, 548 
rheumatic, 580 
ulcerative, 526 
voice-users', 560 
Sound and voice, differentiation, 732 
definition, 741 
intensity, 733 
pitch, 734 
quality, 734 
sensation, cause, 738 
Sound-perception, objective, 741, 742 
intellect as factor in, 742 
subjective, 741 s 

Space, postnasal, 18 
Spasm in hereditary nasal syphilis, 163 
of abductors of vocal cords, 644 
of glottis, 644, 648 

adenoids as cause, 209 
in acute laryngitis in children, 643 
in children, 646 
in elongation of uvula, 445 
in hyperplastic rhinitis, 121 
in intubation of larynx, 784 
in nasal hydrorrhea, 143 
of larynx, 644, 648, 649. See also Larynx, 

spasm of. 
of pharynx, 617 

and paralysis of esophagus, differentia- 
tion, 617 
of pharynx, differentiation, 617 
and stricture of esophagus, differentiation, 

617 
diagnosis, differential, 617 
treatment, 617 
Spasmodic barking cough, 633 
croup, 642, 644, 649 



INDEX. 



849 



Spasmodic croup, adenoids as cause, 209 
laryngeal occlusion, 767 
laryngitis, 644, 649. See also Laryngitis, 

spasmodic. 
stenosis of pharynx, 520 
torticollis after adenotomy, 470 
Spasmus glottidis, 644 
Spastic dyspnea and hysterical aphonia, 765 

paraplegia of larynx, 767 
Specific catarrh, 145 
inflammations, 145 
rhinitis, 145 
Speculum, Allen's nasal, 36 
bivalve nasal, 37 
Gleason's nasal, 38 
Ingal's, 683 
Jackson's slide, 719 
self-retaining, 308 

separable, for passing bronchoscopes, 718 
Speech, 732 

central brain mechanism of, 750 
conversion of voice into, 735 
defects of, affecting mental development, 
750 
age in, 751 

conditions producing, 750 
etiology, 749, 751 
objective, 749 
subjective, 749 
from fatigue, 753 
heredity in, 751 
in backward children, 750 
in feeble-mindedness, 754 
mechanical, 752 
paralysis as cause, 753 
treatment, 755 
definition, 734, 744 
development of, 744 

effect of diseases on, 746 

of environments on, 746 
hard and soft palate, tongue, and buccal 

cavities important factors in, 747 
mechanisms in, 749 
auditory, 749 
oral, 749 
vocal, 749 
stop positions in, 747 
anterior, 747 
middle, 748 
posterior, 748 
imitation of, 745 
impression made by, 741 
Makuen's definition, 734 
peculiarities in manner of, 753 
self-consciousness in, 745 
transmission of thought and ideas through 
medium of, 745 
Speech-production, 736 
Sperm-inheritance of nasal syphilis, 162 
Sphenoidal sinuses, anatomy, 21 
carcinoma of, 398 
catarrhal inflammation, 394 
diagnosis, 394 
discharge in, 394 
headache in, 394 
pain in, 394 
prognosis, 394 
symptoms, 394 
treatment, 395 
diseases of, 394 

difficult of diagnosis, 394 
empyema of, 395. See also Empyema of 

sphenoidal sinus. 
infectious, acute, 398 
mucocele of, 399 
myxoma of, 398 
osteoma of, 398 
sarcoma of, 398 
sj-philis of, 398 
tumors of, 398 
tuberculosis of, 398 
sinusitis, eye signs, 419 

54 



Sphenoidal turbinate bones, 21 
Sphenopalatine artery, anatomy, 24 
ganglion, neuralgia of, 357 
treatment, 357 
Spirochseta pallida, 146 
Spirochetes of syphilis, distribution, 156 
Splint, Carter's nasal, 342 
Splitting of thyroid cartilage, 796 
Sporadic catarrh, common, 74 
Spot, blind, enlargement of, in diseases of ac- 
cessory sinuses, 419 
Spots, cough, 634 
Spurious croup, 634, 649 
Staff of Wrisberg, 626 
Stammering, 748, 749, 751 

as neurosis of nasopharynx, 442 
treatment, 755 

Makuen's method, 755, 756 
McCormick's method, 755 
Staphylococcus, 70 

in infective pharyngitis, 527 
pyogenes albus, 70 
aureus, 70 
citreus, 70 
Stasis, venous, as cause of atrophic phar- 
yngitis, 573 
Steam sterilization, 49 

sterilizer, 49, 50 
Stenosis of larynx, acquired, 629. See also 
Larynx, stenosis of, acquired. 
congenital, 628 
from tuberculosis, 705 
syphilitic, treatment, 703 
of pharynx, 519 

congenital, treatment, 628 

disease of vertebral column as cause, 520 

enlargement of thyroid gland as cause, 520 

extrinsic, 520 

Hodgkin's disease as cause, 520 

retropharyngeal abscess as cause, 520 

spasmodic, 520 
symptoms, 519 
traumatic, 519 

treatment, 519 
treatment, 519 
tubercular, 519 
Sterilization of instruments for office •work, 49 

steam, 49, 50 
Sterilizer, Ferguson's, 50 
Lewis' electric, 50 
steam, 49, 50 
Stevens' tonsil-knife, 496 
Stiffness in throat in keratosis of pharynx, 

609, 612 
Stimulants as cause of chronic pharvngitis, 

560 
Stoerck's cough spots, 634 
Stomach, affections of, as neuroses, reflex 
nasal, 214 
cough, 634 
Stomatitis, ulcerative, and Vincent's angina, 

relation, 559 
Stop positions in development of speech, 747 
anterior, 747 
middle, 748 
posterior, 748 
Straining of voice as cause of follicular phar- 
yngitis, 567 
Streptococcal infection in croupous pharyn- 
gitis, 529 
of pharynx, 547 
symptoms, 547 
treatment, 548 
pharyngitis, 526 
Streptococcus as cause of infective pharvn- 
gitis, 527 
pyogenes in croupous pharyngitis, 529 
Stricture of esophagus and spasm of pharynx, 

differentiation, 617 
Stridor of larynx, congenital, 646 
etiology, 646 
symptoms, 646 



850 



INDEX. 



Stridulous angina, 649 

laryngitis, 649 
Strumous rhinitis, 85 
Stubb's mouth-gag, 468 
Stucky's forceps, 251 
Stuttering, 748, 751 
Subepithelial buds in keratosis of pharynx, 

609 
Subglottic laryngitis, 642 

Submaxillary lymphatic glands, enlargement 
of, in primary stage of acquired nasal syph- 
ilis, 150 
Submucosa, 60. See also Mucous mem- 
brane. 
Submucous infiltration of septum, 335 
Subperiosteal abscess in confined suppuration 

of frontal sinus, 408 
Sulphocyanid in saliva, 57 
Summer catarrh, 194 
Sun's rays, condition simulating hyperesthetic 

rhinitis due to, 199 
Superficial tonsillitis, acute, 471. See also 

Tonsillitis, superficial, acute. 
Suppurating ethmoiditis, 387. See also Eth- 

moiditis, suppurating. 
Suppuration, confined, of antrum of High- 
more, 368 
alcohol in, 370 
diagnosis, 370 
etiology, 368 
fistula in, 369 
nasal obstruction in, 369 
pain in, 369 
prognosis, 370 
pus in, 369 
swelling in, 369 
teeth in, 369 
tenderness in, 369 
treatment, 373 
of frontal sinus, 405 

abscess of brain in, 408, 409 
Bryan's operation, 409 
caries in, 408 
cerebral symptoms, 406 
complications, 408 
diagnosis, 407 
etiology, 405 
eye-symptoms, 406 
headache in, 406 
impairment of smell in, 406 
intracranial complications, 408 
Killian's operation for, 410 

after-treatment, 412 
meningitis in, 408 
necrosis in, 408 
Ogston-Luc operation for, 409 
pachymeningitis in, 409 
pain in, 406 
periostitis in, 408 
pressure-effects in, 406 
prognosis, 408 
pyemia in, 409 
radical operation for, 410 
after-treatment, 412 
rupture in, 406, 407 
■ subperiosteal abscess in, 408 
symptoms, 406 
thinning of walls in, 406 
thrombophlebitis in, 409 
treatment, 409 
of accessory sinuses, 350 
of cavernous sinus from empyema of sphe- 
noidal sinus, 397 
of ethmoidal sinuses, 387. See also Eth- 
moiditis, suppurating. 
of larynx, 654 

of pharyngeal bursa and empyema of sphe- 
noidal sinus, differentiation, 397 
Suppurative inflammation, chronic, of frontal 
sinus, 404. See also Empyema of frontal 
sinus, purulent, chronic. 
of mucous membrane, 66 



Suppurative laryngitis, 654, 656. See also 
Laryngitis, suppurative. 

meningitis in empyema of sphenoidal sinus, 
397 

pharyngitis, 526, 527 
Supraglottic laryngitis, acute, 642 
Supra-orbital neuralgia, reflex nasal, 213 
Surgical tonsil, 491 

age in diagnosis of, 493 
Sweats in acute glanders of pharynx, 598, 

599 
Swivel-knife, 320 
Swollen bodies, 24 
Symptomatic laryngitis, 688 
Syncope in epistaxis, 221 
Synechia, 325 

acquired, 325 

congenital, 325 

etiology, 325 

nasal obstruction in, 326 

symptoms, 325 

treatment, 326 

ulceration in, 326 
Syphilis, abnormalities of soft palate from, 
450 

and cancer of pharynx, differentiation, 272 

as cause of chondritis of larynx, 669 

congenital, of nose, 162 

diagnosis of chondritis of larynx due to, 675 

hyperplastic laryngitis in, 689 

inherited, of nose, 162 

nasal, 145. See also Nasal syphilis. 

neosalvarsan in, 156. See also Neosalvarsan 
in syphilis. 

of antrum of Highmore, 379 

of ethmoidal sinuses, 393 

of larynx, 694. See also Larynx, syphilis of. 

of mucous membrane, 66 

of nasopharynx, 592. See also Pharynx, 
syphilis of. 

of pharynx, 592. See also Pharynx, syph- 
ilis of. 

of septum, 346 

of sphenoidal sinuses, 398 

of tonsil, 592. See also Pharynx, syphilis 

°f- 

pathology of chondritis of larynx due to, 
669 

predisposing to acute simple rhinitis, 75 

prognosis of chondritis of larynx due to, 676 

salvarsan in, 156. See also Salvarsan in 
syphilis. 

spirochetes of, distribution, 156 

symptoms of chondritis of larynx due to, 671 

tarda, 162 

tertiary, salvarsan and iodid of potassium in, 
157 

treatment of chondritis of larynx due to, 677 

ulceration of uvula in, 448 
Syphilitic diseases of eye, salvarsan in, 158 

hyperplasia of pharynx, congenital, 592, 593 
treatment, 593 

laryngitis and chronic laryngitis, differen- 
tiation, 682 

ozena, 145 

rhinitis, 145 

stenosis of larynx, treatment, 703 

ulceration of septum, 329 
salvarsan in, 158 

ulcers, nasal, 188 
deep, 189 
superficial, 188 
Syringe, Dennis', 709 

Donelan's, 712 

Freeman's, 424 

paraffin, 155 

postnasal, 47 

Quinlan's, for injection of paraffin, 155 

Roux's antitoxin, 542 
Systemic diseases, influence of, on mucous 
membrane, 51 
necessity of urinary analysis in, 51 



INDEX. 



851 



Tabes, laryngismus stridulus in, 645 
Taking cold in intumescent rhinitis, 115 
Tardy syphilis, 162 

Taste, impairment of, in acute pharyngitis, 
523 
in atrophic rhinitis due to pre-existing 

lesion, 134 
in chronic pharyngitis, 564 

simple rhinitis, 109 
in follicular pharyngitis, 570 
in pharyngeal tonsil, 463 
in preglottic tonsillitis, 514 
in secondary stage of acquired nasal 
syphilis, 150 
relation of nasal cavities to, 28 
Teeth, antrum of Highmore and, relation, 358 
artificial, removal of, from esophagus, 722 
Hutchinson's, in hereditary nasal syphilis, 

163 
in cause of acute purulent inflammation of 
antrum of Highmore, 365 
of mycosis of faucial tonsil, 512 
in confined suppuration of antrum of High- 
more, 369 
lesions of, from diseases of accessory sinuses, 
351 
Telangiectoma of respiratory tract, 286 

epistaxis in, 286 
Temperature after intravenous injection of 
salvarsan, 160 
in acute catarrhal laryngitis, 636 
in diphtheria, 534 
in gangrenous pharyngitis, 549 
in reflex nasal asthma, 211 
sudden changes of, predisposing to taking 
cold, 73 
Tenacular-forceps, 510 

Tenderness in acute catarrhal inflammation 
of frontal sinus, 400 
purulent inflammation of antrum of 
Highmore, 365 
in chronic catarrhal inflammation of fron- 
tal sinus, 401 
purulent inflammation of antrum of 
Highmore, 368 
in confined suppuration of antrum of High- 
more, 369 
Tenor voice, 734 

Tensor paralysis, laryngeal, internal, 775 
Teratoma of respirators' tract, 286 
Test, therapeutic, in hereditary nasal syphilis, 

163 
Thepsco aspirating apparatus, 374 
Therapeutic test in hereditary nasal syphilis, 

163 
Thickened mucous membrane after epidemic 
influenza, 89 
in hyperplastic rhinitis, 118 
Thickness of septum, 19 

Thinning of walls in confined suppuration of 
frontal sinus, 406 
in mucocele of frontal sinus, 413 
Third tonsil, 26, 457 
Thirst in cryptic tonsillitis, 476 
Thorner's improved O'Dwyer's intubation 

set, 779 
Thornwaldt's disease, 432 

and empyema of sphenoidal sinus, differ- 
entiation, 397 
Thought and language, relation of, 747 
Throat, angioneurotic edema of, 585 

condition of, in follicular pharyngitis, 569 

consumption of, 703 

dryness and tickling in, in intumescent 

rhinitis, 115 
erysipelas of, 529 
gouty, 655 
in acute catarrhal laryngitis, 636 

rheumatic pharyngitis, 582 
in atrophic pharyngitis, 575 
in chronic rheumatic pharyngitis, 584 
in herpes of pharynx, 605 



Throat, method of examining, in diphtheria, 
537 
sensitiveness of, in infective pharyngitis, 527 
sore, aphthous, 605 

clergyman's, 560, 566, 684 
gouty, 580, 584, 655 
hospital, 526 

in rhinopharyngitis mutilans, 441 
membranous, 605 
putrid, 530, 548 
rheumatic, 580 
ulcerative, 526 
voice-user's, 560 
stiffness in, in keratosis of pharynx, 609, 612 
Throat-tire in chronic pharyngitis, 564 
Thrombophlebitis in confined suppuration of 

frontal sinus, 409 
Thrombosis of cavernous sinus from suppurat- 
ing ethmoiditis, 390, 391 
of jugular veins from tonsillar abscess, 484 
sinus, cavernous, eve signs, 420 
Thymic asthma, 210, 645 

tracheostenosis, 210 
Thymus gland, pressure from, as cause of 

laryngismus stridulus, 645 
Thyro-arytenoids, paralysis of, 775 
Thyroid cartilage, chondritis of, 671 
symptoms, 674 
splitting of, 796 
gland, enlargement of, as cause of stenosis 
of pharynx, 520 
Thyroiditis, acute, edema of glottis in, 657 
Thyrotomy, 796 

after-treatment, 796 
indications, 796 
Tic douloureux, reflex nasal, 213 
Tickling sensation in acute uvulitis, 447 
Timbre, 734, 735 

altered, in hyperplastic rhinitis, 119 
controlled by size of lungs, larynx, and 
resonance tube, 737 
Tinnitus aurium in acute superficial tonsil- 
litis, 472 
in chronic nasopharyngitis, 429 
in empyema of sphenoidal sinus, 395 
Tobacco, habitual use of, as cause of pre- 
glottic tonsillitis, 514 
in cause of follicular pharyngitis, 567 
Tone of voice, 734 
clang of, 734 
controlled by size of lungs, larynx, and 

resonance tube, 737 
quality, 734 
Tongue an important factor in development 
of speech, 747, 748 
black, involving pharynx, 555 
dilatation of veins at base of, 517 
disease of, as cause of laryngismus strid- 
ulus, 645 
in diphtheria, 533 
Tongue-depressor, 39 
adjustable blades for, 40 
method of using, in examination, 39 
Tonsil, actinomycosis of, 600. See also Phar- 
ynx, actinomycosis of. 
adherent, 491 
angioma of, 243 
as portal of infection, 492 
buccal, 513 
carcinoma of, 272 

and sarcoma, differentiation, 284 
treatment, 273 
discrete, 457 
diseases of, 456 
enlarged, as cause of cough, 632 

cervical glands and, relationship, 492 
epipharyngeal, 457 
examination of, in diagnosis of diphtheria, 

537 
faucial, 456, 470. See also Faucial tonsil. 
fibroma of, 250 
treatment, 251 



852 



INDEX. 



Tonsil, finger enucleation of, 504 
Doyle's method, 507 
Richardson's method, 504 
fourth, 513 
function of, 492 
glanders of, 597. See also Pharynx, 

glanders of. 
hemostat, Corwin's, 499 
imbedded, 491 
in lupus of pharynx, 591 
infectious granuloma of, 586 
instruments, Makuen's, 494 
intestinal, 538 

involvement of, in epidemic influenza, 88 
keratosis of, 608. See also Pharynx, kera- 
tosis of. 
laryngeal, 456, 517 

lingual, 456, 513. See also Lingual tonsil. 
lipoma of, 253 

lupus of, 590. See also Pharynx, lupus of. 
Luschka's, 26, 457 
lymphosarcoma of, 283 
nasal, 456 

operation. See Tonsillectomy. 
pharyngeal, 26, 44, 238, 456, 457. See also 

Pharyngeal tonsil. 
rheumatism and, relationship, 492 
sarcoma of, 283. See also Sarcoma of 

tonsil. 
snare, Lewis', 502 
surgical, 491 

age in diagnosis of, 493 
syphilis of, 592. See also Pharynx, syph- 
ilis of. 
third, 26, 457 
tubal, 456, 463 
tuberculosis of, 586. See also Pharynx, 

tuberculosis of. 
voice and, 493 
Tonsil-clamp, Pierce's, 499 
Tonsil-grapsing forceps, Watson's, 495 
Tonsil-knife, 501 

Stevens', 496 
Tonsillar abscess, 482. See also Abscess, 

tonsillar. 
crypts, 26 
lacunse, 26 
Tonsillectomy, 495 
after-treatment, 497 
anesthetic in, 495 
hemophilia after, 499 
hemorrhage after, 497 
secondary, 498, 499 
treatment, 498, 499 
in bleeders, 499 
in tuberculosis, 494 
indications, 492 
Kyle's method, 500-502 
posture in, 495 

secondary hemorrhage after, 498, 499 
Sluder's method, 502 
technic, 495 

voice after, 492, 493, 494, 500 
Tonsillitis, 472 

acute, and diphtheria, differentiation, 536 
and membranous laryngitis, differentiation, 

665 
caseous, 509 

crypts in, 509 

history, 509 

symptoms, 509 

treatment, 510 
catarrhal, acute, 472 
cryptic, 471, 474, 492 

abscess-formation in, 475 

constipation in, 476 

cough in, 475 

diagnosis, 477 

ear-symptoms in, 476 

etiology, 474 

anatomical structure, 474 

facial expression in, 476 



Tonsillitis, cryptic, febrile symptoms, 476 

general systemic condition in course, 474 

glandular involvement in, 476 

inspection of tonsil, 476 

liquefaction-necrosis in, 475 

otitis media in, 476 

pain in, 475 

pathology, 474 

perverted secretion in, 476 

prognosis, 477 

respiration in, 475 

serous exudate in, 474 

submerged and adherent tonsil in, 476 
treatment, 477 

symptoms, 475 
in children, 476 

synonyms, 474 

thirst in, 476 

treatment, 477 

urine in, 476 

voice in, 475 
fibrinous, 485 
follicular, 474 

gouty, 478. See also Tonsillitis, rheumatic. 
herpetic, 480 

bacteria as cause, 481 

diagnosis, 481 

etiology, 480 

pathology, 481 

prognosis, 481 

symptoms, 481 

treatment, 481 

vesicles in, 481 
hyperplastic, 487 
hypertrophic, 487 

adhesions to palatine fold in, 490 

after infectious diseases, 487 

age in, 487 

associated with adenoids, 490 

bacteria in, 490 

connective tissue in, 488 

cough in, 490 

diagnosis, 491 

ear-symptoms in, 490 

etiology, 487 

facial expression in, 490 

glandular variety, 487 
pathology, 488 

heredity in, 487 

imperfect mobility of uvula in, 489 

interference with swallowing in, 490 
with venous circulation as cause, 488 

involvement of Eustachian tube in, 489, 
490 

irregularities of climate as cause, 487 

irritation as cause, 487 

mouth-breathing in, 490 

nasal obstruction in, 489 

pathology, 488 

prognosis, 491 

reflex neuroses from, 490 

regurgitation in, 489 

sex in, 487 

soft variety, 487 
pathology, 488 

symptoms, 489 

synonyms, 487 

tonsillar abscess as cause, 487 

tonsillectomy in, 495. See also Tonsillec- 
tomy. 

treatment, 491 

varieties, 487 

voice in, 490 
lacunar, 471, 474 

ulcerative, 471 
membranous, 485 

bacteria in, 486 

coagulation-necrosis in, 486 

glandular involvement in, 486 

pain in, 486 

pathology, 486 

symptoms, 486 



INDEX. 



853 



Tonsillitis, membranous, synonyms, 485 
treatment, -486 
ulcers in, 486 
voice in, 486 
parenchymatous, 471, 474 
phlegmonous, 482 
preglottie, 514 

after infectious diseases, 514 
after influenza, 514 
cough in, 514 
diagnosis, 515 
elongation of uvula in, 514 
etiology, 514 

glandular involvement in, 514 
habitual use of tobacco as cause, 514 
impairment of taste in, 514 
pathology, 514 
prognosis, 515 
symptoms, 514 
treatment, 515 

uric-acid diathesis as cause, 514 
voice in, 514 
rheumatic, 478 
diagnosis, 479 

enlargement of tonsils in, 478 
headache in, 479 
increase of connective-tissue element of 

tonsil in, 479 
odor in, 478 
pain in, 479 
prognosis, 479 
symptoms, 478 
treatment, 479 
uric acid in urine in, 478 
urine in, 478, 479 
voice in, 478 
superficial, acute, 471 
complications, 473 
definition, 471 
diagnosis, 473 
ear-symptoms, 472 
elongation of uvula in, 473 
etiology, 472 
otitis media in, 473 
pain in, 472 
pathology, 472 
prognosis, 473 
symptoms, 472 

in children, 472 
synonyms, 472 
tinnitus aurium in, 472 
torticollis in, 472 
treatment, 473 
voice in, 472 
ulcerative, 486 
Tonsillolith, 510 
Tonsillotyphoid, 557 
Tonsil-punch, Farlow's, 497, 498 

Pierce's, 497 
Torpid liver as cause of chronic nasopharyn- 
gitis, 426 
Torticollis in acute superficial tonsillitis, 472 

spasmodic, after adenotomy, 470 
Toynbee's oral gymnastic method of teaching 

deaf to hear, 750 
Trachea, 18 

pressure on, expiratory dyspnea from, 210 
Tracheal dilator, Trousseau's, 791 
rings, chondritis of, 671 
tube, Cohen's, 788 
Tracheitis in hyperplastic rhinitis, 121 
Tracheoscope, Ferguson's, for infants and 
children, 719 
Mosher's, for adults, 719 
Tracheostenosis, thymic, 210 
Tracheotomy, 786 

contra-indications, 786 
definition, 786 
high, 788 
indications, 786 
instruments, 787 
laryngotomy, 790 



Tracheotomy, low, 789 

operative complications and dangers, 790 

procedures, 786 
palliative, 797 

postoperative care, dangers, and complica- 
tions, 791 
tube, Keen's, 791 
Richard's, 791 
Trachoma, 691 
of larynx, 691 
of vocal cords, 691 
Transillumination in acute purulent inflam- 
mation of frontal sinus, 403 
of accessory sinuses, 372 
of antrum of Highmore, 370 
through mouth, 371 
Transilluminator, Coakley's, 372 
Transplantation of bone, Carter's operation, 

for nasal deformity, 345 
Traumatic acute simple rhinitis, 76 
deflection of septum, 294 
laryngitis, 653 
edema in, 653 
treatment, 654 
pharyngitis, 549 
rhinitis, 102 

stenosis of pharynx, 519 
Traumatism as cause of chondritis of larvnx, 
668 
of epistaxis, 217 
of suppurating ethmoiditis, 387 
diagnosis of chondritis of larynx due to, 675 
of nose as cause of cough, 633 
pathology of chondritis of larynx due to, 671 
prognosis of chondritis of larynx due to, 676 
symptoms of chondritis of larynx due to, 674 
treatment of chondritis of larvnx due to, 677 
Trocar, Myles', 374 

Trophic lesions, atrophic rhinitis due to, 139 
Trophoneurotic ulcer, 329 
Trousseau's tracheal dilator, 791 
True croup, 661 
Tubal tonsil, 446, 463 
Tubercle bacillus, 67, 70, 166 

as cause of tuberculosis of larynx, 703, 704 
in nasal lupus, 171 
Tubercles in tuberculosis of pharynx, 586 
miliary, in nasal tuberculosis, 167 
symptoms, 168 
Tubercular laryngitis, 703 

and chronic laryngitis, differentiation, 681 
and syphilis of larynx, differentiation, 700 
leprosy, 177 
pathology, 177 
prognosis, 179 
stenosis of pharynx, 519 
ulcers in nasal tuberculosis, 167 
symptoms, 168 
nasal, 188 

treatment, 1S8 
Tuberculosis after pneumococcic infection of 
pharynx, 548 
as cause of chondritis of larynx, 669 
diagnosis of chondritis of larynx due to. 

675 
in ozena. 125 

nasal, 166. See also Nasal tuberculosis. 
nasalis, 166 

of antrum of Highmore, 379 
of ethmoidal sinuses, 393 
of larynx, 703. See also Larynx, tubercu- 
losis of. 
of mucous membrane, 67 
of nasopharynx, 586. See also Pharynx, 

tuberculosis of. 
of pharynx, 586. See also Pharynx, tuber- 
culosis of. 
of sphenoidal sinuses, 398 
of tonsils, 586. See also Pharynx, tubercu- 
losis of. 
pathology of chondritis of larynx due to, 670 
predisposing to acute simple rhinitis, 75 



854 



INDEX. 



Tuberculosis, prognosis of chondritis of larynx 
due to, 676 
pulmonary, and foreign body in larynx, dif- 
ferentiation, 729 . 
symptoms of chondritis of larynx due to, 

671 
tonsil and, relationship, 492 
tonsillectomy in, 494 
treatment of chondritis of larynx due to, 

677 
ulceration of uvula in, 448 
Tuberculous rhinitis, 85 
stenosis of larynx, 631 
Tumors, embryonic connective-tissue, 278 
epithelial, of respiratory tract, 267 
in hyperplastic rhinitis, 121 
mixed, of respiratory tract, 286 
of antrum of Highmore, 383 
diagnosis, 384 
treatment, 384 
of ethmoidal sinuses, 393 

treatment, 393 
of frontal sinus, 415 

of larynx as cause of chondritis of larynx, 
669 
of cough, 633 
diagnosis, early, importance of, 794 
microscopic examination before opera- 
tion, 795 
of respiratory tract, 232. See also Respira- 
tory tract, tumors of. 
of septum, 347 
of sphenoidal sinus, 398 
Turban epiglottis, 706 
Turbinated corpora cavernosa, 24 
Turbinals, 19 
anatomy, 19 

atrophy of, in atrophic rhinitis, 128 
enlarged, in chronic simple rhinitis, 110 

removal, 111 
exostosis of, 245 
fourth, 19, fig. 1 
hypertrophy of, 116 
in atrophic rhinitis due to pre-existing 

lesion, 132 
increase in, in hyperplastic rhinitis, 118 
inferior, 20, 43, 44 

condition of, in hyperplastic rhinitis, 118, 
119 
injury of, emphysema of face from, 113 
middle, 19, 44 

condition of, in hyperplastic rhinitis, 118, 
119 
sphenoidal, 21 
superior, 19, 44 

swelling of, in cyanotic rhinitis, 144 
Typhoid fever, acute laryngitis in, 641 
simple rhinitis in, 83 
diagnosis of chondritis of larynx due to, 

675 
nasal ulcers in, 190 
pathology of chondritis of larvnx due to, 

670 
pharynx in, 557 
prognosis of chondritis of larvnx due to, 

676 
pyemic metastasis in, as cause of chon- 
dritis of larynx, 669 
symptoms of chondritis of larynx due to, 
672 
emphysema of tissues of neck in, 
673 
treatment of chondritis of larynx due to, 
677 
Typhus fever, acute laryngitis in, 640 
pharynx in, 557 
treatment, 557 



Ulceration, hemorrhagic, of pharynx, 55] 
in acquired tertiary nasal syphilis, 151 
in acute glanders of pharynx, 598 



Ulceration in atrophic rhinitis secondary- to 

lesion elsewhere, 139 
in cancer of larynx, 276 

of soft palate, 271 
in chronic laryngitis, 681 
in cyanotic rhinitis, 144 
in infective pharyngitis, 527 
in lupus of pharynx, 591 
in mycosis of lingual tonsil, 516 
in nasal leprosy, 179 

lupus, 170 
in occupation-rhinitis, 103 
in pneumococcic infection of pharynx, 548 
in sarcoma of larynx, 285 

of nasopharynx, 280 

of nose, 279 

of pharynx, 282 

of tonsil, 283 
in secondary stage of acquired nasal syphilis, 

147 
in synechia, 326 
in tertiary syphilis of larynx, 698 

of pharynx, 595 
in tonsillar abscess, 483 
in tuberculosis of larynx, 706 
of pharynx from rheumatism, 581 
of septum. 328. See also Septum, ulceration 

of. 
of soft palate, 450 

of uvula, 447. See also Uvula, ulceration of. 
syphilitic, salvarsan in, 158 
Ulcerative lacunar, tonsillitis, 471 
laryngitis, recurrent, 696 
rhinitis, 104 
sore throat, 526 
stomatitis and Vincent's angina, relation, 

559 
tonsillitis, 486 
Ulcers, catarrhal, in acute nasopharyngitis, 423 
in anemia of pharynx, 614 

treatment, 614 
in atrophic rhinitis, 127 
in membranous tonsillitis, 486 
in nasal glanders, 175 
in rhinopharyngitis mutilans, 441 
in tuberculosis of pharynx, 587 
nasal, 184 

catarrhal, 185 
treatment, 185 

chemic, 187 
treatment, 188 

classification, 184 

compound, malignant, 188 

croupous or fibrinous, 190 

diabetic, 187 

due to foreign bodies, 186 

eczematous, 185 
treatment, 186 

herpetic, 185 
treatment, 185 

in diphtheria, 190 

in glanders, 189 

in measles, 190 

in rheumatism, 190 

in scarlet fever, 190 

in small-pox, 190 

in typhoid fever, 190 

in typhus fever, 190 

infected, 188 

leprous, 189 

lupoid, 188 

neuroparalytic, 186 
treatment, 186 

non-infected, 185 

scorbutic, 186 
treatment, 186 

simple, 185 

syphilitic, 188 
deep, 189 
superficial, 188 

tubercular, 188 
treatment, 188 



INDEX. 



855 



Ulcers, nasal, varicose, 187 
treatment, 187 
superficial, as symptoms of syphilis of lar- 
ynx, 696 
trophoneurotic, 329 
tubercular, in nasal tuberculosis, 167 
symptoms, 168 
Uric-acid diathesis as cause of laryngismus 
stridulus, 645 

in acute rheumatic pharyngitis, 580 
in urine in rheumatic tonsillitis, 478 
Urinary examination, importance, 51 

in determining general condition, 58 
Urine in acute pharyngitis, 523 

in cause of preglottic tonsillitis, 514 
in cryptic tonsillitis, 476 
in diphtheria, 534 
in rheumatic tonsillitis, 478, 479 
uric acid in, in rheumatic tonsillitis, 478 
Urticaria, neurosis, reflex nasal, 214 
of pharynx, 604, 605 

edema of glottis from, 605 
Uterine cough, 634 
Uvula, abscess of, 447 
adhesions of, 450 
angioma of, 242 
bacillus of diphtheria on, 448 
bifid, 443 

cough in, 444 

treatment, 444 
carcinoma of, 270 
diseases of, 443 
edema of, 446 
elongation, 444 

as cause of cough, 632 

of laryngismus stridulus, 645 

asthma in, 445 

choking in, 445 

chronic laryngitis in, 445 

cough in, 444 

diagnosis, 445 

etiology, 444 

in acute superficial tonsillitis, 473 

in anemia of pharynx, 615 

in pharyngeal tonsil, 463 

in preglottic tonsillitis, 514 

irritation in, 444 

pathology, 444 

prognosis, 445 

spasm of glottis in, 445 

symptoms, 444 

tickling sensation in, 444 

treatment, 445 

voice in, 445 
emphysema of, 449 

treatment, 449 
imrjerfect mobility, in hypertrophic tonsil- 
litis, 489 
infiltration of, acute, 446 
inflammatory' diseases of, 446 
length of, 444 
mycosis of, 448 

non-inflammatory diseases, 450 
paralysis of, 453 
rudimentary malformations, 443 
shrinking of, in lupus of pharynx, 591 
swelling and relaxation, in chronic naso- 
pharyngitis, 430 
ulceration of, 447 

in syphilis, 448 

in tuberculosis, 448 

postnasal catarrh from, 448 
Uvulitis, acute, 446 

cough in, 447 

difficulty and pain on swallowing in, 447 

dyspneic symptoms, 447 

etiology, 446 

irritation in, 447 

pathology, 447 

symptoms, 447 

synonyms, 446 

tickling sensation in, 447 



Uvulitis, acute, treatment, 447 
chronic, 447 
symptoms, 447 
treatment, 447 
Uvulotomy, 445 

hemorrhage after treatment, 446 



Vaccine therapy in chronic ethmoidal suppu- 
ration, 95 
frontal sinusitis, 94 
sinusitis, 94 
in diseases of accessory sinuses, 93, 94 
dosage, 96 
indications, 94 
of nose, 93 
in infections of antrum and accessory 

spaces, 95 
in long-standing infections, 93 
limitations of, 93 
Vapors predisposing to taking cold, 74 
Varices of lingual tonsil, 517. See also Lin- 
gual tonsil, varices of. 
Varicose condition of vessels in chronic phar- 
yngitis, 563 
ulcers, nasal, 187 

treatment. 187 < 
Variola, acute laryngitis in, 640 
simple rhinitis in, 83 
and glanders of pharynx, differentiation, 

599 
nasal ulcers in, 190 
pharynx in, 554 
treatment, 555 
Varioloid, pharynx in, 558 
Vascular supply in nasal lupus, 171 
Vasomotor reflex nasal asthma, etiology, 210 
Vault of pharynx, 26 
Vegetations, adenoid, 457 
Veins, dilatation of, at base of tongue, 517 
jugular, thrombosis of, from tonsillar ab- 
scess, 484 
of nose, 290 
Venous circulation, interference with, as 
cause of hypertrophic tonsillitis, 488 
plexuses, 24 

stasis as cause of atrophic pharyngitis, 573 
Ventilation, poor, predisposing to taking cold, 

73 
Ventricles, laryngeal, prolapse of, 730 
Vertebra?, caries of, as cause of laryngismus 
stridulus, 645 
cervical, caries of, retropharyngeal abscess 

associated with, 603 
involvement of, in tertiary syphilis of phar- 
ynx, 596 
Vertebral column, disease of, as cause of 

stenosis of pharynx, 520 
Vertigo in empyema of sphenoidal sinus, 396 
laryngeal, 767 
prognosis, 768 
synonym, 767 
treatment, 768 
neurosis, reflex nasal, 214 
Vestibule, 19 
anatomy, 19 
epithelium of, 24 
framework of, 19 
lining membrane of, 24 
Vicarious epistaxis, 219 
Vincent's angina, 558 

and diphtheria, differentiation, 559 
and ulcerative stomatitis, relation, 559 
bacteria in, 559 
symptoms, 559 
varieties, 559 
Viscera, congestion of, causing alteration in 

mucous membrane, 51 
Vision, field of, changes in, relation of disease 

of accessory sinuses to, 419 
Vocal cords in tuberculosis of larynx, 707 
paralysis of, 768 



856 



INDEX. 



Vocal cords, paralysis of, in syphilis of larynx, 
695 

spasm of abductors of, 644 

trachoma of, 691 
nodules, 691 
Voice, 732 

after tonsillectomy, 492, 493, 494, 500 
alteration in, in atrophic rhinitis due to 
pre-existing lesion, 135 

in defective hearing, 739 
alto, 734 

and sound, differentiation, 732 
baritone, 734 
bass, 734 

carrying quality, 734 
change of, at puberty, improper, 752 
larynx in, 752 
treatment, 752 
compass of, 734 

condition of, in intumescent rhinitis, 115 
conditions producing change in, 750 
contralto, 734 

conversion of, into speech, 735 
definition of, 734 

effect of climate and environments on, 732, 
733 

of facial contour on, 732 
force of, 735 

impression made by, 741 
in acute catarrhal laryngitis, 636 

laryngitis in children, 643 

nasopharyngitis, 423 

pharyngitis, 523 

simple rhinitis, 77 

superficial tonsillitis, 472 
in anemia of larynx, 690 
in atrophic rhinitis secondary to lesion else- 
where, 138 
in cancer of larynx, 276 

of soft palate, 271 
in chronic laryngitis, 678, 679, 680 

nasopharyngitis, 426, 429 

pharyngitis, 561, 563, 564, 566, 567, 569 

rheumatic pharyngitis, 584 
in cryptic tonsillitis, 475 
in cyanotic pharyngitis, 579 
in different nationalities, 732 
in diphtheria, 533 
in dry laryngitis, 686 
in edematous laryngitis, 658 
in educated persons, 732 
in elongation of uvula, 445 
in fibroma of nasal passage, 248 
in follicular laryngitis, 684, 685 
in foreign bodies in larynx, 728 
in hemorrhagic laryngitis, 667 
in hereditary nasal syphilis, 163 
in hyperemia of larynx, 690 
in hypertrophic tonsillitis, 490 
in laryngeal hemorrhage, 713 
in lupus of pharynx, 591 
in membranous laryngitis, 663 

tonsillitis, 486 
in mucocele of larynx, 266 
in nasal leprosy, 178 

polypus, 259 
in pemphigus of larynx, 691 
in perforation of soft palate, 450 
in pharyngeal tonsil, 463 
in preglottic tonsillitis, 514 
in rheumatic laryngitis, 655 

tonsillitis, 478 
in sarcoma of larvnx, 285 

of pharynx, 282 

of tonsil, 283 



Voice in singer's nodules, 693 
in spasmodic laryngitis, 651 
in suppurative laryngitis, 655 
in syphilis of larynx, 695 
in tuberculosis of larynx, 705 

of pharynx, 587 
in uneducated persons, 732 
individuality of, 737 
intensity of, 733 
Makuen's definition of, 734 
mezzo-soprano, 734 
mutation of, 735, 749 
pathologic condition causing straining in 

execution, 736 
pitch of, 734 

modification, 733 
production of, lungs, larynx, and resonance 
tube in, 737 

mechanisms in, 732, 735 
quality of, 734 

influence of shape of resonant apparatus 
on, 734 
range of, 733 
reach of, 734 
relation of acoustics of mouth to, 738 

to hearing, 738 

effect of drugs and stimulants in, 740 
singing, 734 
soprano, 734 
speaking, 734 

straining of, as cause of follicular pharyn- 
gitis, 567 
tenor, 734 

timbre of, 734, 735. See also Timbre. 
tone of, 734. See also Tone of voice. 
tonsil and, 493 
training in executing, 736 
varieties, 734 
volume of, controlled by size of lungs, 

larynx, and resonance tube, 737 
Voice-users' sore throat, 560 
Volume of voice controlled by size of lungs, 

larynx, and resonance tube, 737 
Vomiting in diphtheria, 533 
von Hoffman's bacillus, 70 

in diphtheria, 532 



Wassermann reaction in diagnosis of early 
hereditary nasal syphilis, 164 
in primary stage of acquired nasal syph- 
ilis, 152 
in syphilis of larynx, 700 
influence of salvarsan on, 161 
positive, in syphilis, salvarsan after, 157 
Water, snow-, as cause of cyanotic phar- 
yngitis, 579 
Watery infiltration in tonsillar abscess, 482 
Watson's operation for septal deflection, 314 

tonsil-grasping forceps, 495 
Wax, hardened, in ear as cause of cough, 632 . 
Welsbach light for illumination, 30 
Whistler's cutting dilator, 629 
White's operation for saddle-back nose, 339 
Whooping-cough, acute simple rhinitis in, 83 
and membranous laryngitis, differentiation, 
665 
Word-blindness, 753 
Wrisberg, staff of, 626 



Xerostoma in pharyngeal tonsil, 463 

Yankauer's operation for septal deviation, 
321 



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Nervous and Mental 
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Dercum's Mental Diseases 

Clinical Manual of Mental Diseases. By Francis X. Dercum, 
Ph. D., M. D., Professor of Nervous and Mental Diseases at Jefferson 
Medical College, Philadelphia. Octavo of 425 pages. Cloth, $3.00 net. 

TWO PRINTINGS IN FIVE MONTHS 

This is a book really useful to the family physician — a book that tells you 
definitely how to diagnose, how to treat — either at home or in an institution — all 
classes of mental diseases. First, Dr. Dercum takes up the various primary 
forms of mental disease, giving emphasis to those you meet in your daily practice 
as general practitioner — delirium, confusion, stupor. Then melancholia, mania, 
the insanities of early life, paranoia, the neurasthenic-neuropathic disorders, and 
the dementias follow. The mental disturbances of the infections (syphilis, tubercu- 
losis, malaria, pellagra, rheumatic fever, etc.), the various forms of intoxicational 
insanities, those due to metabolic disorders, visceral disease, diseases of the 
nervous system are all given you — and from your viewpoint. An important sec- 
tion is that devoted to the insanities of pregnancy . An entire part is devoted to 
the psychologic ijiterpretations of symptoms as evolved by Freud and his disciples. 
You get a full discussion of the role of dreams. 

The Medical World 

'• This book gives just the information necessary, and gives it in a style studiously adapted 
to the needs of the general physician." 



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Church and Peterson's 
Nervous and Mental Diseases 



Nervous and Mental Diseases. By Archibald Church, M. D., 
Professor of Nervous and Mental Diseases and Medical Jurisprudence, 
Northwestern University Medical School, Chicago ; and Frederick 
Peterson, M. D., President New York State Commission on Lunacy : 
Professor of Psychiatry at the College of Physicians and Surgeons, 
N. Y. Handsome octavo, 934 pages ; 341 illustrations. Cloth, $ 5.0c 
net ; Half Morocco, $6.50 net. 

THE NEW (7th) EDITION 

For this new seventh edition the entire work has been most thoroughly re- 
vised. To show with what thoroughness the authors have revised their work, we 
point out that in the nervous section alone over one hundred and fifty interpola- 
tions have been made, and, in addition, well over three hundred minor correc- 
tions. The chapters on Meningitis, Aphasia, Poliomyelitis, Pellagra, and Pituitary 
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Amyatonia has been introduced. The section on Mental Diseases has been 
wholly rearranged to conform to the latest classification, some obsolete matter 
struck out, and much new matter added. A number of chapters have been re- 
written. This seventh edition embodies every substantial advance in the domains 
of nervous and mental diseases. 

American Journal of the Medical Sciences 

" This edition has been revised, new illustrations added, and some new matter, and really 
is two books. . . . The descriptions of disease are clear, directions as to treatment definite, 
and disputed matters and theories are omitted. Altogether it is a most useful text-book." 



Kaplan's Serology of Nervous and 
Mental Diseases 

Serology of Nervous and Mental Diseases. By D. M. Kaplan, 

M. D., Director of Clinical and Research Laboratories, Neurological 

Institute, New York City. Octavo of 400 pages, illustrated. 

JUST READY 

This is an entirely new work, giving you the indications, contra-indications, 
preparation of patients, technic, after-phenomena, after-care, and disposal of the 
fluids obtained by lumbar puncture. You get a full discussion of the serology of 
all nervous and mental diseases of non-luetic etiology (including disorders of 
internal secretion), and of every type of luetic nervous and mental disease, giv- 
ing the Wassermann reaction in detail, the use of salvarsan and neosalvarsan, etc. 



MENTAL DISEASES AND HYGIENE. 



Brill's Psychanalysis 

THE PRACTICAL APPLICATION OF ALL FREUD'S THEORIES 

Psychanalysis : Its Theories and Practical Application. By A. A. 
Brill, Ph. B., M. D., Clinical Assistant in Neurology at Columbia 
University Medical School. Octavo of 392 pages. Cloth, $3.00 net. 

JUST OUT— NEW (2d) EDITION 

To the general practitioner, who first sees these ' ' borderline ' ' cases (the 
neuroses and the psychoses), as well as to those specially interested in neurologic 
work, Dr. Brill' s work will prove most valuable. Dr. Brill has had wide clinical 
experience, both in America and in Europe. The results of this experience you 
get in this book. Here you get the practical application of all Freud's theories — 
and from the pen of a man thoroughly competent to write. 

Unlike other forms of psychotherapy, psychanalysis deals with the neuroses 
as entities. It does not treat them as symptoms, as do hypnotism, suggestion, 
and persuasion. Such treatment is similar to treating the cough or fever regard- 
less of the causal disease. Psychanalysis concerns itself with the individual as a 
personality. It gives you a real insight into the neuroses and the psychoses. 

Journal American Medical Association 

"A splendid summary of Freud's writings. We believe this book to be the best one- 
volume exposition of the Freudian doctrine that has been written for the non-specialist." 



Hunt's Diagnostic Symptoms 
of Nervous Diseases 

Diagnostic Symptoms of Nervous Diseases. By Edward L 
Hunt, M. D., Instructor in Neurology and Assistant Chief of Clinic, 
College of Physicians and Surgeons, New York. i2mo of 229 pages, 
illustrated. Cloth, $1.50 net. 

JUST READY 

Dr. Hunt gives you here those salient points and leading symptoms that will 
enable you to diagnose nervous and mental diseases. The book has chapters on 
examination, deformities, paralysis, tremors, trophic disorders, gaits, ataxia, con- 
vulsions, sensation, reflexes, eye symptoms, speech disturbances, aphasia, and 
electric reactions. The chapters on gaits takes up each gait in detail, giving you 
its characteristics and the diseases in which it occurs. Under reflexes the methods 
of eliciting the reflexes are clearly given and the diseases suggested by their 
absence stated. The value of the eye in diagnosis is brought out and the symp- 
toms interpreted. 



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American Illustrated Dictionary 

New (7th) Edition— 5000 Sold in Two Months 

The American Illustrated Medical Dictionary. A new and com- 
plete dictionary of the terms used in Medicine, Surgery. Dentistry, 
Pharmacy, Chemistry, Veterinary Science, Nursing, and kindred 
branches; with over 100 new and elaborate tables and many hand- 
some illustrations. By W. A. Newman Dorland, M. D. Large 
octavo, 1 107 pages, bound in full flexible leather, $4. 50 net ; with thumb 
index, $5.00 net. 

The American Illustrated Medical Dictionary defines hundreds of terms not 
defined in any other dictionary — bar none. It gives the capitalization and pro- 
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words. Every word has a separate paragraph, thus making it easy to find a 
word quickly. The tables of arteries, muscles, nerves, veins, etc., are of the 
greatest help in assembling anatomic facts. Every word is given its definition — a 
definition that defines in the fewest possible words. 

Howard A. Kelly, M. D., Johns Hopkins University, Baltimore. 

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Goodnow's First- Year Nursing 

First=Year Nursing. By Minnie Goodnow, R. N., formerly Superintendent of the 
Women's Hospital, Denver. i2mo of 328 pages, illustrated. Cloth, $1.50 net. 

Miss Goodnow's work deals entirely with the practical side of first-year nursing work. It 
is the application of text-book knowledge. It tells the nurse how to do those things she is 
called upon to do in her first year in the training school — the actual ward work. 

Roberts' Bacteriology and Pathology for Nurses 

Bacteriology and Pathology for Nurses. By Jay G. Roberts, Ph. G., M. D., 

Oskaloosa, Iowa. i2mo of 206 pages, illustrated. Cloth, $1.25 net. 

This new work is practical in the strictest sense. Written specially for nurses, it confines 
itself to information that the nurse should know. All unessential matter is excluded. The 
style is concise and to the point, yet clear and plain. The text is illustrated throughout. 



DISEASES OF -CHILDREN. 



KerrV Diagnostics qf 
Diseases qf Children 

Diagnostics of the Diseases of Children. By LeGrand Kerr, 
M. D., Professor of Diseases of Children, Brooklyn Postgraduate Med- 
ical School, Brooklyn. Octavo of 542 pages, fully illustrated. Cloth, 
$5.00 net; Half Morocco, $6.50 net. 

FOR THE PRACTITIONER 

Dr. Kerr's work differs from all others on the diagnosis of diseases of children 
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throughout has been to render a correct diagnosis as early in the course of the 
disease as possible, and for this reason differential diagnosis is presented from 
the very earliest symptoms. The many original illustrations will be found 
helpful. 

New York State Journal of Medicine 

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Kerley's Pediatrics 



Practice of Pediatrics. By Charles Gilmore Kerley, M. D., 
Professor of Diseases of Children, New York Polyclinic Medical School 
and Hospital. Octavo of 878 pages, illustrated. Cloth, $6.00 net; 
Half Morocco, $7.50 net, 

A NEW WORK— REPRINTED IN ONE MONTH 

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diseases, the feeding and growth of the baby, the care of the mother's breasts, 
artificial feeding, milk modification and sterilization, diet for older children — from 
a monograph of 125 pages. Then are discussed in detail every disease of child- 
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the minute, including every new method of proved value — with the exact technic. 
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Sanders' Nursing 

Modern Methods in Nursing. By Georgiana J. Sanders, formerly 
Superintendent of Nurses at the Massachusetts General Hospital. 1 2mo 
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Miss Sanders' book gives only modern methods. Then it gives the details of 
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in which ward work is taken up makes her book indispensable for teaching pur- 
poses. In giving directions for mustard baths, poultices, etc., the quantities axe 
given exactly. This is an important point often overlooked. 



Stoney's Nursing 

Practical Points in Nursing. By Emily A. M. Stoney. i2moof 
495 P a g es > illustrated. Cloth, $1.75 net. 

THE NEW (4th) EDITION 

In this volume the author explains the entire range of private nursing as dis- 
tinguished from hospital nursing, and the nurse is instructed how best to meet the 
various emergencies of medical and surgical cases when distant from medical or 
surgical aid or when thrown on her own resources. An especially valuable feature 
will be found in the directions how to improvise everything ordinarily needed in the 
sick-room. 



Stoney's Technic for Nurses 

Bacteriology and Surgical Technic for Nurses. By Emily A. M. 
Stoney, formerly Superintendent at Carnev Hospital, South Boston. 
Revised by Frederic R. Griffith, M. D., Surgeon, of New York. 
i2mo, 311 pages, illustrated. Cloth, $1.50 net. 

THE NEW (3d) EDITION 
Trained Nurse and Hospital Review 

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tneir hospital course and in private practice." 



NURSING. 



Nursing in Diseases of the 
Eye, Ear, Nose, and Throat 

Nursing in Diseases of the Eye, Ear, Nose, and Throat. By the 

Committee on Nurses of the Manhattan Eye, Ear, and Throat Hospital: 
J. Edward Giles, M. D., Surgeon in the Eye Department ; Arthur B. 
Duel, M. D. (Chairman), Surgeon in the Ear Department ; Harmon 
Smith, M. D., Surgeon in the Throat Department. Assisted by John 
R. Shannon, M. D., Assistant Surgeon in the Eye Department ; and 
John R. Page, M. D., Assistant Surgeon in the Ear Department. With 
chapters by Herbert B. Wilcox, M. D., Attending Physician to the 
Hospital; and Miss Eugenia D. Ayers, Superintendent of Nurses. 
l2mo of 260 pages, illustrated. Cloth, #1.50 net. 

A VALUABLE BOOK 

This is a practical book, prepared by surgeons who, from their experience in 
the operating amphitheater and at the bedside, have realized the shortcomings of 
present nursing books in regard to eye, ear, nose, and throat nursing. The scope 
of the work has been limited to what an intelligent nurse should know, and the 
style throughout is simple, plain, and definite. 

New York Medical Journal 

" Every side of the question has been fully taken into consideration." 

Stoney's 
Materia Medica for Nurses 



Practical Materia Medica for Nurses, with an Appendix containing 
Poisons and their Antidotes, with Poison-Emergencies ; Mineral Waters ; 
Weights and Measures ; Dose-List, and a Glossary of the Terms used 
in Materia Medica and Therapeutics. By Emily A. M. Stoney, for- 
merly of the Carney Hospital, South Boston. i2mo of 300 pages, 
Cloth, $1.50 net. 

THE NEW (3d) EDITION 

In making the revision for this new third edition, all the newer drugs have 
been introduced and fully discussed. The consideration of the drugs includes 
their sources and composition, theiT various preparations, physiologic actions, 
directions for administering, and the symptoms and treatment of poisoning. 

Journal of the American Medical Association 

'* So far as we can see, it contains everything that a nurse ought to know in regard to drugs. 
As a reference-book for nurses it will without question be very useful." 



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Hoxie and Lapt&d's Medicine for Nurses New (2d) Edition 

Medicine for Nurses and Housemothers. By George Howard Hoxie, 
M. D., Physician to the German Hospital, Kansas City, Mo.; and Pearl L. 
Laptad, formerly Principal of the Training School for Nurses, University of 
Kansas. i2mo of 351 pages, illustrated. Cloth, $1.50 net. 

This work is truly a practice of medicine for the nurse, enabling her to recognize any 
signs and changes that may occur between visits of the physician, and, if necessary, to 
combat them until the physician's arrival. This information the author presents in a way 
most acceptable, particularly emphasizing the nurse's part. 

Trained Nurse and Hospital Review 

" This book has our unqualified approval." 

McCombs' Diseases of Children for Nurses New(2d)Edition 

Diseases of Children for Nurses. By Robert S. McCombs, M. D., 
Instructor of Nurses at the Children's Hospital of Philadelphia. i2mo of 
470 pages, illustrated. Cloth, $2.00 net. 

Dr. McCombs* experience in lecturing to nurses has enabled him to emphasize just those 
points that nurses most need to know. The nursing side has been written by head nurses, 
especially praiseworthy being the work of Miss Jennie Manly. 

National Hospital Record 

" We have needed a good work on children's diseases adapted for nurses' use, and this 
volume admirably fills the want." 

Wilson's Obstetric Nursing The New (2d) Edition 

A Reference Hand=Book of Obstetric Nursing. By W. Reynolds 
Wilson, M. D., Visiting Physician to the Philadelphia Lying-in Charity. 
32mo of 256 pages, illustrated. Flexible leather, $1.25 net. 

Dr. Wilson's work discusses the subject of obstetrics entirely from the nurse's point of 
view, presenting in detail everything connected with pregnancy and labor and their man- 
agement. The text is copiously illustrated. / 

American Journal of Obstetrics 

" Every page emphasizes the nurse's relation to the case." 

Fruhwald and Westcott on Children 

Diseases of Children. A Practical Reference Book for Students and 
Practitioners. By Professor Dr. Ferdinand Fruhwald, of Vienna. 
Edited, with additions, by Thompson S. Westcott, M. D., University of 
Pennsylvania. Octavo, 533 pages, 176 illustrations. Cloth, $4.50 net. 

Boyd's State Registration for Nurses 

State Registration for Nurses. By Louie Croft Boyd, R. N., Graduate 
Colorado Training-school for Nurses. Octavo of 42 pages. 50 cents net. 



NURSING. 



Aikens* Primary Studies for Nurses New (2d) Edition 

Primary Studies for Nurses : A Text-Book for First-year Pupil 
Nurses. By Charlotte A. Aikens, formerly Director of Sibley Memorial 
Hospital, Washington, D. C. i2mo of 437 pages, illus. Cloth, #1.75 net. 

This work brings together in concise form well-rounded courses of lessons 
in all subjects which, with practical nursing technic, constitute the primary 
studies in a nursing course. 

Trained Nurse and Hospital Review 

"It is safe to say that any pupil who has mastered even the major portion of this work 
would be one of the best prepared first-year pupils that ever stood for examination." 



Aikens' Clinical Studies for Nurses New (2d) Edition 

Clinical Studies for Nurses. By Charlotte A. Aikens, formerly 
Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 
569 pages, illustrated. Cloth, $2.00 net. 

This new work is written along the same lines as Miss Aikens' former 
work on "Primary Studies," to which it is a companion volume. It takes 
up all subjects taught during the second and third years and takes them 
up in a concise, forceful way. 

Dietetic and Hygienic Gazette 

" There is a large amount of practical information in this book which the experienced 
nurse, as well as the undergraduate, will consult with profit. The illustrations are 
numerous and well selected." 

Aikens' Training-School Methods 

Hospital Training-School Methods and the Head Nurse. By 
Charlotte A. Aikens, formerly Director of Sibley Memorial Hospital, 
Washington, D. C. i2mo of 267 pages. Cloth, $1.50 net. 

Trained Nurse and Hospital Review 

" There is not a chapter in the book that does not contain valuable suggestions." 

Aikens 9 Hospital Management Extremely Practical 

Hospital Management. By Charlotte A. Aikens, formerly Direc- 
tor of Sibley Memorial Hospital, Washington, D. C. i2mo of 488 
pages, illustrated. Cloth, $3.00 net. 

The Medical Record 

" Tells in concise form exactly what a hospital should do and how it should be run, 
from the scrubwoman up to its financing. A valuable addition to our literature on this 
subject." 



io SAUNDERS' BOOKS ON 

Bolduan and Grund's Bacteriology for Nurses 

Applied Bacteriology for Nurses. By Charles F. Bolduan, 
M. D., Assistant to the General Medical Officer; and Marie Grund, 
M. D., Bacteriologist, Research Laboratory, Department of Health, 
New York City. 12 mo of 155 pages, illustrated. Cloth, #1.25 net. 

We were fortunate in getting these practical physicians to write this work. It gives par- 
ticular emphasis to the immediate application of bacteriology to nursing, only the really 
practical being included. A study of all the modes of infection transmission is presented. 
At the end of each chapter are suggestions for practical demonstration. 

Register's Fever Nursing 

A Text-Book on Practical Fever Nursing. By Edward C. 
E-EGister, M. D., Professor of the Practice of Medicine in the North 
Carolina Medical College. i2mo of 352 pages. Cloth, $2.50 net. 

Hecker, Trumpp, and Abt on Children 

Atlas and Epitome of Diseases of Children. By Dr. R. Hecker 
and Dr. J. Trumpp, of Munich. Edited, with additions, by Isaac A. 
Abt, M.D., Assistant Professor of Diseases of Children, Rush Medical 
College, Chicago. With 48 colored plates, 144 text-cuts, and 453 pages 
of text. Cloth, $5.00 net. 

The many excellent lithographic plates represent cases seen in the authors' clinics, and 
have been selected with great care, keeping constantly in mind the practical needs of the 
general practitioner. These beautiful pictures are so true to nature that their study is 
equivalent to actual clinical observation. The editor, Dr. Isaac A. Abt, has added all new 
methods of treatment. 

Lewis* Anatomy and Physiology The New (3d) Edition 

Anatomy and Physiology for Nurses. By LeRoy Lewis, M. D., 
Formerly Surgeon to and Lecturer on Anatomy and Physiology for 
Nurses at the Lewis Hospital, Bay City, Michigan. i2mo of 344 pages, 
with 161 illustrations. Cloth, $1.75 net. 

A demand for such a work as th.s. treating the subjects from the nurses' point of view, 
has long existed. Dr. Lewis has based the plan and scope of this work on the methods 
employed by him in teaching these branches, making the text unusually simple and clear. 

The Nurses Journal of the Pacific Coast 

" It is not in any sense rudimentary, but comprehensive in its treatment of the subjects 
in hand. The application of the knowledge of anatomy in the care of the patient is 
emphasized." 

Friedenwald and Ruhrah's Dietetics New (3d) Edition 

Dietetics for Nurses. By Julius Friedenwald, M. D., Professor 
of Diseases of the Stomach, and John Ruhrah, M. D., Professor of 
Diseases of Children, College of Physicians and Surgeons, Baltimore. 
i2mo volume of 431 pages. Cloth, $1.50 net. 

This work has been prepared to meet the needs of the nurse, both in the training 
school and after graduation. It aims to give the essentials of dietetics, considering briefly 
the physiology of digestion and the various classes of foods and the part they play in 
nutrition. 

American Journal of Nursing 

" It is exactly the book for which nurses and others have long and vainly sought. A 
simple manual of dietetics, which does not turn into a cook-book at the end of the first 
or second chapter. 



NURSING AND CHILDREN. \\ 



Paul's Fever Nursing New (2d) Edition 

Nursing in the Acute Infectious Fevers. By George P. Paul, 
M. D., formerly Assistant Visiting Physician to the Samaritan Hospital, 
Troy, N. Y. i2mo of 246 pages. Cloth, #1.00 net. 

Dr. Paul has taken great pains in the presentation of the care and management of each 
fever. The book treats of fevers in general, then each fever is discussed individually, and 
the latter part of the book deals with practical procedures and valuable information. 

The London Lancet 

" The book is an excellent one and will be of value to those for whom it is intended. 
It is well arranged, the text is clear and full, and the illustrations are good." 

Paul's Materia Medica for Nurses New (2d) Edition 

Materia Medica for Nurses. By George P. Paul, M. D., formerly 
Assistant Visiting Physician to the Samaritan Hospital, Troy. i2mo oJ 
282 pages. Cloth, $1.50 net. 

Dr. Paul arranges the physiologic actions of the drugs according to the action of the 
drug and not the organ acted upon. An important section is that on pretoxic signs, 
giving the warnings of the full action or the beginning toxic effects of the drug, which, 
if heeded, may prevent many cases of drug poisoning. 

The Medical Record, New York 

"This volume will be of real help to nurses; the material is well selected and well 
arranged, and the book is as readable as it is useful." 

Pyle's Personal Hygiene The New ( 5 th) Edition 

A Manual of Personal Hygiene : Proper Living upon a Physiologic 
Basis. By Eminent Specialists. Edited by Walter L. Pyle, A. M., 
M.D., Assistant Surgeon to Wills Eye Hospital, Philadelphia. Octavo 
volume of 515 pages, fully illustrated. Cloth, $1.50 net. 

The book has been thoroughly revised for this new edition, and a new chapter on 
Food Adulteration by Dr. Harvey W. Wiley added. There are important chapters 
on Domestic Hygiene and Home Gymnastics, Hydrotherapy, Mechanotherapy, and 
First Aid Measures. 

Boston Medical and Surgical Journal 

" The work has been excellently done, there is no undue repetition, and the writers 
have succeeded unusually well in presenting facts of practical significance based on sound 
knowledge." 

Galbraith's Four Epochs of Woman's Life second Edition 

The Four Epochs of Woman's Life. By Anna M. Galbraith, 
M.D. With an Introductory Note by John H. Musser, M.D., Univer- 
sity of Pennsylvania. 1 21110 of 247 pages. Cloth, #1.50 net. 
Birmingham Medical Review 

" We do not as a rule care for medical books written for the instruction of the public; 
but we must admit that the advice in Dr. Galbraith's work is in the main wise and whole- 
some." 

Spratling on Epilepsy 

Epilepsy and Its Treatment. By William P. Spratling, M. D., Pro- 
fessor of Physiology and Nervous Diseases, College of Physicians and Sur- 
geons, Baltimore. Octavo of 522 pages, fully illustrated. Cloth, $4.00 net. 
The Lancet, London 

"Dr. Spratling's work is written throughout in a clear and readable style. . . . The 
work is a mine of information on the whole subject of epilepsy and its treatment." 



12 SAUNDERS' BOOKS ON 



Macfarlane's Gynecology for Nurses New (2d) Edition 

A Reference Hand-Book of Gynecology for Nurses. By Cath- 
arine Macfarlane, M. D., Gynecologist to the Woman's Hospital of 
Philadelphia. i6mo of 150 pages, with 70 illustrations. Flexible 
leather, $1.25 net. 

A. M. Seabrook, M. D., Woman's Medical College of Philadelphia. 

" It is a most admirable little book, covering in a concise but attractive way the subject from 
the nurse's standpoint." 

Galbraith's Personal Hygiene for Women 

Personal Hygiene and Physical Training for Women. By 
Anna M. Galbraith, M.D., Fellow New York Academy of Medicine, 
121110 of 371 pages, with original illustrations. Cloth, $2.00 net. 

Dietetic and Hygienic Gazette 

" It contains just the sort of information which is very greatly needed by the weaker sex. Its illus- 
trations are excellent." 

De Lee's Obstetrics for Nurses New (4th) Edition 

Obstetrics for Nurses. By Joseph B. DeLee, M. D., Professor of 
Obstetrics in the Northwestern University Medical School. 1 2mo vol- 
ume of 508 pages, fully illustrated. Cloth, $2.50 net. 

J. Clifton Edgar, M. D., 

Professor of Obstetrics and Clinical Midwifery, Cornell Medical School, N. Y. 

" It is far-and-away the best that has come to my notice, and I shall take great pleasure in recom- 
mending it to my nurses and students as well." 

Davis' Obstetric Nursing New (4th) Edition 

Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M., 
M. D. , Professor of Obstetrics, Jefferson Medical College and Philadel- 
phia Polyclinic. i2mo of 480 pages, illustrated. Buckram, $1.75 net. 

The Lancet, London 

" Not only nurses, but even newly qualified medical men, would learn a great deal by a perusal of 
this book. It is written in a clear and pleasant style, and is a work we can recommend." 

Beck's Hand-Book for Nurses New (ad) Edition 

A Reference Hand-Book for Nurses. By Amanda K. Beck, of 
Chicago, 111. 32mo of 200 pages. Flexible leather, $1.25 net. 

Aikens* Home Nurse's Hand-Book 

Home Nurse's Hand-Book. By Charlotte A. Aikens. i2moof 276 
pages, illustrated. Cloth, $1.50 net. 

The point about this work is this : It tells yon and shows you just how to do those 
little but important things often omitted from other nursing books. " Home Treat- 
ments " and " Points to be Remembered" — terse, cri so reminders — stand out as par- 
ticularly practical. Just the book for those who have the home-care of the sick. 



CHILD REX AND HYGIEXE. 13 

Griffith's Care of the Baby 

The Care of the Baby. By J. P. Crozer Griffith, M. D., Clinical 
Professor of Diseases of Children, University of Penn. ; Physician to the 
Children's Hospital, Phila. i2mo, 455 pp. Illustrated. Cloth, $1.50 net. 

THE NEW (5th) EDITION 

The author has endeavored to furnish a reliable guide for mothers. He has 
made his statements plain and easily understood, so that the volume will be of 
service to mothers and nurses. 

New York Medical Journal 

"We are confident if this ltttle work could find its wa/ into the hands of every trained 
nurse and of every mother, infant mortality would be lessened by at least fifty per cent." 



Grulee's Infant Feeding 

Infant Feeding. By Clifford G. Grulee, M. D., Assistant Pro- 
fessor of Pediatrics at Rush Medical College. Octavo of 3 16 pages, illus- 
trated, including 8 in colors. Cloth, $3.00 net. 

JUST ISSUED NEW (2d) EDITION 

Dr. Grulee tells you how to feed the infant. He tells you — and shows by clear 
illustrations — the technic of giving the child the breast. Then artificial feeding is 
thoughtfully presented, including a number of simple formulas. The colored illus- 
trations showing the actual shapes and appearances of stools are extremely 
valuable. 



Ruhrah's Diseases of Children 

A Manual of Diseases of Children. By John Ruhrah, M. D., 
Professor of Diseases of Children, College of Physicians and Surgeons, 
Baltimore. i2mo of 534 pages, fully illustrated. Flexible leather, 
$2.50 net. 

THE NEW (3d) EDITION 

In revising this work for the second edition Dr. Ruhrah has carefully in- 
corporated all the latest knowledge on the subject. All the important facts are 
given concisely and explicitly, the therapeutics of infancy and childhood being 
outlined very carefully and clearly. There are also directions for dosage and 
prescribing, and many useful prescriptions are included. 

American Journal of the Medical Sciences 

"Treatment has been satisfactorily covered, being quite in accord with the best teaching, 
yet withal broadly general and free from stock prescriptions." 



i 4 SAUNDERS' BOOKS ON 

Reefer's Military Hygiene 

Military Hygiene and Sanitation. By Lieut.-Col. Frank R. 

Keefer, Professor of Military Hygiene, United States Military Academy, 

West Point. i2mo of 200 pages, illustrated. 

JUST READY 

This is a concise, though complete text-book on this subject, containing 
chapters on the care of troops, recruits and recruiting, personal hygiene, physical 
training, preventable diseases, clothing, equipment, water-supply, foods and their 
preparation, hygiene and sanitation of posts and barracks, the troopship, hygiene 
and sanitation of marches, camps, and battlefields, disposal of wastes, tropical and 
arctic service, venereal diseases, alcohol and other narcotics, and a glossary. 



Bergey's Hygiene 

The Principles of Hygiene : A Practical Manual for Students, 
Physicians, and Health Officers. By D. H. Bergey, A. M., M. D., 
Assistant Professor of Bacteriology in the University of Pennsylvania. 
Octavo volume of 555 pages, illustrated. Cloth, $3.00 net. 

• FOURTH EDITION 

This book is intended to meet the needs of students of medicine in the 
acquirement of a knowledge of those principles upon which modern hygienic 
practises are based, and to aid physicians and health officers in familiarizing 
themselves with the advances made in hygiene and sanitation in recent years. 
This fourth edition has been very carefully revised, and much new matter 
added, so as to include the most recent advancements. 

Buffalo Medical Journal 

•' It will be found of value to the practitioner of medicine and the practical sanitarian ; and 
students of architecture, who need to consider problems of heating, lighting, ventilation, water 
supply, and sewage disposal, may consult it with profit." 



Fiske's Human Body 

Structure and Functions of the Body. By Annette Fiske, A.M., 
Graduate of the Waltham Training School for Nurses. i2mo of 221 
pages, illustrated. Cloth, $1.25 net. 



LEGAL MEDICINE 15 



Bohm and Painter's Massage 

Massage. By Max Bohm, M. D., of Berlin, Germany. Edited, with an 
Introduction, by Charles F. Painter, M, D., Professor of Orthopedic Sur- 
gery at Tufts College Medical School, Boston. Octavo of 91 pages, with 70 
practical illustrations. Cloth, Si. 75 net. 

Draper's Legal Medicine 

A Text=Book of Legal Medicine. By Frank Winthrop Draper, A. M., 
M. D., Late Professor of Legal Medicine in Harvard University, Boston. 
Octavo of 573 pages, illustrated. Cloth, $4.00 net ; Half Morocco, $5.50 net. 

Chapman's Medical Jurisprudence Third Edition 

Medical Jurisprudence, Insanity, and Toxicology. By Henry C. 
Chapman, M. D., late Professor of Institutes of Medicine and Medical Juris- 
prudence in Jefferson Medical College, Philadelphia. i2mo of 329 pages, 
illustrated. Cloth, Si. 7 5 net. 

Golebiewski and Bailey's Accident Diseases 

Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. 

Golebiewski, of Berlin. Edited, with additions, by Pearce Bailey, M. D. f 
Consulting Neurologist to St. Luke's Hospital, New York. With 71 colored 
illustrations on 40 plates, 143 text illustrations, and 549 pages of text. Cloth, 
$4.00 net. In Saunders Hand-Atlas Series. 

Hofmann and Peterson's Legal Medicine Hand-Ati^es 

Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna. 
Edited by Frederick Peterson, M. D., Professor of Psychiatry in the 
College of Physicians and Surgeons, New York. With 120 colored figures 
on 56 plates and 193 half-tone illustrations. Cloth, $3.50 net. 

Jakob and Fisher's Nervous System Sat Atias"i 

Atlas and Epitome of the Nervous System and its Diseases. By 

Professor Dr. Chr. Jakob, of Erlangen. Edited, with additions, by Ed- 
ward D. Fisher, M. D., University and Bellevue Hospital Medical College. 
With 83 plates and copious text. Cloth, $3.50 net. 

Crothers' Morphinism and Narcomania 

Morphinism and Narcomania. By T. D. Crothers, M. D. i2mo of 
351 p^ges. Cloth, $2.00 net. 

Peterson and Haines' Legal Medicine and Toxicology 

A thoroughly revised edition of this work is now in press. Every advance in 
these related subjects will be included, bringing the work right down to date. 



16 SAUNDERS' BOOKS ON CHILDREN. 

American Pocket Dictionary New 8th) Edition 

American Pocket Medical Dictionary. Edited by W. A. New- 
man Dorland, M. D., Editor "American Illustrated Medical Dic- 
tionary." Containing the pronunciation and definition of the principal 
words used in medicine and kindred sciences, with 64 extensive tables. 
With 677 pages. Flexible leather, with gold edges, £1.00 net; with 
patent thumb index, $1.25 net. 

" I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., Dean 
of the Jefferson Medical College, Philadelphia. 

Morrow's Immediate Care of Injured New C 2d ) Edition 

Immediate Care of the Injured. By Albert S. Morrow, M. D., 
Adjunct Professor of Surgery at the New York Polyclinic. Octavo of 360 
pages, with 242 illustrations. Cloth, $2.50 net. 

Dr. Morrow's book on emergency procedures is written in a definite and decisive style, 
the reader being told just what to do in every emergency. It is a practical book for every 
day use, and the large number of excellent illustrations can not but make the treatment to 
be pursued in any case clear and intelligible. Physicians and nurses will find it indispensible. 

Powell's Diseases Of Children Third Edition, Revised 

Essentials of the Diseases of Children. By William M. Powell, 
M. D. Revised by Alfred Hand, Jr.; A. B., M. D., Dispensary 
Physician and Pathologist to the Children's Hospital, Philadelphia. 
i2mo volume of 259 pages. Cloth, $1.00 net. In Saunders' 
Question- Compend Series. 

Shaw on Nervous Diseases and Insanity Fifth Edition 

Essentials of Nervous Diseases and Insanity: Their Symptoms 
and Treatment. A Manual for Students and Practitioners. By the late 
John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and 
Nervous System, Long Island College Hospital, New York. i2mo of 
204 pages, illustrated. Cloth, #1.00 net. In Saunders' Question- Com- 
pend Series. 

*' Clearly and intelligently written ; we have noted few inaccuracies and several sug- 
gestive points. Some affections unmentioned in many of the large text-books are noted." 
— Boston Medical and Surgical Journal. 

Starr's Diets for Infants and Children 

Diets for Infants and Children in Health and in Disease. By 
Louis Starr, M. D., Consulting Pediatrist to the Maternity Hospital, 
Philadelphia. 230 blanks (pocket-book size). Bound in flexible leather, 
$1.25 net. 

Grafstrom's Mechano-Therapy second Revised Edition 

A Text-book of Mechano-therapy (Massage and Medical Gymnas- 
tics). By Axel V. Grafstrom, B. Sc, M. D., Attending Physician to 
the Gustavus Adolphus Orphange, Jamestown, New York. i2mo, 200 
pages, illustrated. Cloth, #1.25 net. 



